The Medicare Part B administrative appeals process includes the following levels for appeal and their related guidelines:

First Level of Appeal—Redetermination

If you are dissatisfied with the denial of a claim or believe that it was not properly paid, you may request a redetermination. All requests for redetermination must be requested within 120 days of the original claim determination.

States, providers, physicians, or other suppliers with appeal rights must submit written requests indicating what they are appealing and why. There are two acceptable written ways of doing this:

1. A completed CMS-20027 form constitutes a request for redetermination. The contractor supplies these forms upon request by an appellant. Completed means that all applicable spaces are filled out and all necessary attachments are attached.
2. A written request not on the CMS-20027 form . The request contains the following information:

• Beneficiary name
• Medicare Health Insurance Claim number (HICN)
• Specific service(s) and/or item(s) for which the redetermination is being requested
• Specific date(s) of the service
• Name and signature of the party or the representative of the party

Note: The signature must be on the request for redetermination. Signatures contained on medical records are not acceptable as a valid signature for redetermination requests.

Requests for redetermination of nonassigned claims must include a completed Appointment of Representative form (CMS-1696) or a written statement from the beneficiary giving authorization for you to submit a request on his/her behalf. Please see the Appointment of Representative form (CMS-1696) section for further information.

Providers or suppliers may appeal a claim decision by telephone, if the appeal is not complex. An appeal would be considered complex if substantial documentation is needed for its adjudication.

Requests for redetermination should be sent to:

Second Level of Appeal—Reconsideration

If you are not satisfied with the redetermination decision, your next level of appeal is the reconsideration. As stated in the decision letter, the next level of appeal will be performed by another company not associated with National Government Services. All reconsideration requests must be filed within 180 days of the date of receipt of the redetermination. The reconsideration will be performed by the qualified independent contractor (QIC) for all redeterminations issued and mailed January 1, 2006 and after. All redeterminations issued and mailed before January 1, 2006 will have appeals rights with the contractor hearing office.

Please refer to the Centers for Medicare & Medicaid Services (CMS) Internet-Only Manual (IOM) Publication 100-04, Medicare Claims Processing Manual, Chapter 29, Sections 330–345 for information regarding further appeals.

Included with your redetermination decision will be a form with instructions on who and where to send your Reconsideration appeal request. Also included are recommendations on documentation to be submitted with your request. A copy of the Reconsideration Request form (CMS-20033) can also be found on the Centers for Medicare & Medicaid Services (CMS) Web site.

If you have any further questions please contact the Customer Care Department for more information.

Appeal Rights for Dismissals

If the provider thinks the request has been incorrectly dismissed (for example, you believe you did file your request on time), the provider may request a reconsideration of the dismissal by a QIC. The request must be filed within 60 days of receipt of the dismissal letter. The QIC will have 60 days to complete the reconsideration. In the request, please explain why it is believed the dismissal was incorrect. Please note that the QIC will not consider any evidence for establishing coverage of the claim(s) being appealed. The QIC examination will be limited to whether the dismissal was appropriate.

Information regarding the appropriate QIC can be found on the Reconsideration Request form included with the dismissal letter.

If the appeal request was dismissed as incomplete, the provider also has the option to refile the request if any time remains in the filing period (i.e., within 120 days of receipt of the initial determination). When a request is refiled that meets the requirements, the previous dismissal will be vacated.