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Levels of Appeals and Time Limits for Filing and Appeal
Levels of Appeal
The Medicare law consists of five possible appeal levels. The appellant must begin at the first level upon receipt of an initial determination. Each level of appeal, after the initial determination, has procedural steps that must be taken before the appeal can move to the next level. The following table summarizes the types of appeal, the order appeals must be followed, and filing requirements.
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Level I |
Level II |
Level III |
Level IV |
Level V |
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Redetermination |
Reconsideration (qualified independent contractor (QIC) |
Administrative law judge (ALJ) |
Departmental appeals board (DAB) review |
Federal court review |
Time Limit for Filing |
120 days from date of receipt of the notice initial determination |
180 days from date of receipt of the redetermination |
60 days from the date of receipt of the reconsideration |
60 days from the date of receipt of the ALJ hearing decision |
60 days from the date of receipt of DAB decision or declination of review by DAB |
Amount in Controversy (monetary threshold to be met) |
No minimum (none) |
No minimum (none) |
Prior to January 1, 2008, at least $110 remains in controversy
On or after January 1, 2008, at least $120 remains in controversy |
No minimum (none) |
Prior to January 31, 2008, at least $1,130 remains in controversy
On or after January 1, 2008, at least $1,180 remains in controversy |
Where to File Appeal |
Jurisdiction B DME MAC Redeterminations
P.O. Box 6036
Indianapolis, Indiana 46206-6036 |
Qualified independent contractor (QIC) |
HHS Office of Medicare Hearings and Appeals (OMHA) field office |
DAB or ALJ Hearing Office |
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Time Limits for Filing
The time limits for filing an appeal vary according to the type of appeal. The time limits for filing a request for redetermination may be extended in certain situations if good cause for late filing is shown. Some conditions that establish good cause include the following:
1. Incorrect or incomplete information about the subject claim and/or appeal furnished by official sources (Centers for Medicare & Medicaid Services [CMS], durable medical equipment Medicare administrative contractor [DME MAC], or the Social Security Administration) to the individual.
2. Unavoidable circumstances that prevented the individual from timely filing a request for redetermination. Unavoidable circumstances encompass situations that are beyond the individual’s control, such as major floods, fires, tornados, and other natural catastrophes.
Note: Failure of a billing company or other consultant (that the provider, physician, or other supplier has retained) to submit appeals or other information timely does not constitute grounds for finding good cause for the late filing.
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