Change in the Amount in Controversy Requirement for Administrative Law Judge Hearings and Federal District Court Appeals
Provider Types Affected
Physicians, providers, and suppliers submitting claims to Medicare contractors (carriers, DME Medicare Administrative Contractors (DME MAC), fiscal intermediaries (FI), Part A/B Medicare Administrative Contractors (A/B MAC), and/or Regional Home Health Intermediaries (RHHIs)) for services provided to Medicare beneficiaries
Impact on Providers
This article is based on Change Request (CR) 5987 which notifies Medicare contractors of an increase in the Amount in Controversy (AIC) required to sustain Administrative Law Judge (ALJ) and Federal District Court appeal rights beginning January 1, 2008. The amount remaining in controversy requirement for ALJ hearing requests made before January 1, 2008 is $110. The amount remaining in controversy requirement for requests made on or after January 1, 2008 is $120. For Federal District Court review, the amount remaining in controversy goes from $1,130 for requests prior to January 1, 2008 to $1,180 for requests on or after that date.
Background
The Medicare claims appeal process was amended by the Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA). In addition, the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 provides for annual reevaluation (beginning in 2005) of the dollar amount in controversy required for an Administrative Lay Judge (ALJ) hearing and Federal District Court review.
Change Request (CR) 5897 revises the Medicare Claims Processing Manual (Publication 100-4, Chapter 29, Section 330.1, and Section 345.1) to update the Amount In Controversy (AIC) required for an ALJ hearing or Federal District Court review. As of January 1, 2008, the amount remaining in controversy must be at least $120 for an ALJ hearing or at least $1,180 for a Federal District Court review requested on or after January 1, 2008.
Additional Information
The official instruction, CR5987, issued to your carrier, FI, RHHI, A/B MAC, and DME MAC regarding this change may be viewed at http://www.cms.hhs.gov/Transmittals/downloads/R1437CP.pdf on the Centers for Medicare & Medicaid Services (CMS) Web site.
If you have any questions, please contact your carrier, FI, RHHI, A/B MAC, DMERC, or DME MAC at their toll-free number, which may be found at http://www.cms.hhs.gov/MLNProducts/downloads/CallCenterTollNumDirectory.zip on the CMS Web site.
Disclaimer
This article was prepared as a service to the public and is not intended to grant rights or impose obligations. This article may contain references or links to statutes, regulations, or other policy materials. The information provided is only intended to be a general summary. It is not intended to take the place of either the written law or regulations. We encourage readers to review the specific statutes, regulations and other interpretive materials for a full and accurate statement of their contents. CPT only copyright 2007 American Medical Association.
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