- Section 1 Introduction
- Introduction
- Federal Government Administration
- Fundamentals of Medicare: State Responsibilities
- Fundamentals of Medicare: Participating Providers
- Voluntary and Involuntary Termination of Provider Agreement
- Disclosure of Health Insurance Information
- Privacy Act
- National Provider Identifier
- Legacy Provider Numbers/Provider Transaction Access Numbers (PTANs)
- Medicare Administrative Contractors
- Fundamentals of Medicare: Information References
- Acronyms
- Fundamentals of Medicare: Glossary of Terms
- Section 2 Medicare Basics
- The History of Medicare
- What Is the Medicare Program and How Is It Funded?
- Medicare Eligibility and Premiums
- The Social Security Administration and Medicare Enrollment
- The Medicare Card
- Medicare Part A
- Inpatient Hospital Care
- Skilled Nursing Facility Inpatient Care
- Home Health Care Benefit
- The Hospice Benefit
- Medicare Part B Medical Insurance
- Fundamentals of Medicare - Medicare Program Exclusions
- Medicare Advantage Organizations
- Medicare Secondary Payer
- Supplemental Insurance
- Coordination of Benefits Trading Partners
- Section 3 Fraud and Abuse
- Section 4 Getting Ready to Bill Medicare
Section 3: Fraud and Abuse
Appeals Process
Table of Contents
- Appeals Process
- The Five Levels of Appeal
- Appeals Request Process
- What Types of Service Can Be Appealed
- Appointment of Representation
- Who May Be a Representative?
- How Is an Appointment Made?
- How Long is an Appointment of Representative Form Valid?
- When is an Appointment Not Necessary?
- Are Requirements Different if an Attorney is the Representative?
- What Rights Does a Representative Have?
- What Are the Responsibilities of the Representative?
- What if the Appointment of Representation Form is Incomplete or Defective and the Represented Party is the Beneficiary?
- What If the Appointment of Representation Form is Incomplete or Defective and the Represented Party is the Provider?
- Is a Power of Attorney Acceptable as a Valid Appointment?
- What Happens to the Appointment if the Beneficiary Becomes Incapacitated or Dies?
- Who Can File the Appeal if the Beneficiary is Deceased?
- What Information Can Be Disclosed to the Representative?
Appeals Process
Beneficiaries and providers dissatisfied with National Government Services’ claim payment determinations may use the appeals process to resolve any disagreement. The Part A Appeals Department is responsible for processing Part A and Part B redeterminations, forwarding and effectuating reconsiderations, and effectuating ALJ and Medicare Appeals Council (MAC) hearings accurately and on time.
The Five Levels of Appeal
- Redetermination
- Reconsideration
- ALJ hearing
- Medicare Appeals Council
- Federal Court review
Appeals Request Process
The following information must be included with your request for all appeal levels.
- Name
- HIC number
- Dates of service
- Item/service at issue
- Signature
First Level—Redetermination
The first level of appeal is carried out by the A/B MAC, carrier, and/or A/B MAC.
- Time limit to initiate = 120 days from the date of the initial determination
- Time limit to complete the review = 60 days
- Amount in controversy—no minimum amount
Send the completed CMS Medicare Redetermination Request Form (CMS-20027) to the appropriate contact.
Second Level—Reconsideration
Please use the form included with the redetermination decision when sending the reconsideration appeal request.
The second level of appeal is carried out by the QIC.
- Time limit to initiate = 180 days from the date of the redetermination decision
- Time limit to complete the review = 60 days
- Amount in controversy—no minimum amount
Send the completed CMS Medicare Reconsideration Request Form (CMS-20033) to the appropriate contact.
Third Level—Administrative Law Judge Hearing
The third level of appeal is an ALJ hearing.
- Time limit to initiate = 60 days from the date of the QIC decision
- Time limit to complete the review = 90 days
- Amount in controversy = $180 (on or after 1/1/2022)
- Amount in controversy = $180 (on or after 1/1/2021)
Send the completed CMS Request for Medicare Hearing by an ALJ form (CMS-20034A/B) to the appropriate Office of Medicare Hearings and Appeals field office addresses. You can obtain all appeals address information from the Contact Us section of our website.
Fourth Level—Medicare Appeals Council
The fourth level of appeal is carried out by the Medicare Appeals Council (MAC).
- Time limit to initiate = 60 days from the ALJ decision
- Time limit to complete the review = 90 days
- Amount in controversy = no minimum amount
Send requests for a MAC review to:
Department of Health and Human Services
Departmental Appeals Board, MS 6127
Medicare Appeals Council
330 Independence Avenue, SW
Room G-644
Washington, DC 20201
Fifth Level—Federal Court Review
The fifth level of appeal is carried out by the Federal District Court.
- Time limit to initiate = 60 days from the Medicare appeals council decision
- Amount in controversy = $1,760 (on or after 1/1/2022)
- Amount in controversy = $1,760 (on or after 1/1/2021)
Send requests for a judicial review to:
Department of Health and Human Services
General Counsel
200 Independence Avenue, SW
Washington, DC 20201
Clerical Error/Omission Request Process
A clerical error/omission reopening is an action taken to change an initial determination to correct minor errors or omissions outside of the appeal process. Clerical error/omission reopenings are considered “preredeterminations.” All reopenings are granted at the discretion of the contractor. A contractor’s refusal to reopen is may not be appealed; however, a party may request to appeal the initial determination but must do so within the 120-day timeframe.
To facilitate this process, providers should complete the Clerical Error/Omission Reopening Request Form.
What Types of Service Can Be Appealed
The provider, beneficiary, and representative have the right to appeal any initial determination concerning a request for payment under Medicare Part A relating to the following items and services:
- Coverage of furnished items and service
- Amount of the deductible
- Application of the coinsurance provision
- The number of inpatient hospital days used toward the 190-day lifetime limitation of inpatient psychiatric hospital covered days
- The number of lifetime reserve days used
- The number of SNF days used
- The physician certification requirement
- The request for payment requirement
- The beginning and ending of a benefit period
- The medical necessity of the services
- A determination with respect to the limitation of liability provision
- Any issue(s) affecting the amount of benefits payable (including overpayments or underpayments)
- Benefit integrity support center (BISC) denials
- CERT denials
- Prepay and postpay probes
Appointment of Representation
Who May Be a Representative?
A party may appoint any individual, including an attorney, to act as his/her representative in dealing with an A/B MAC. An organization may not be named as a representative; rather an individual from an organization may be a representative. A representative may be appointed at any point in the appeals process. Here is a list of types of individuals that may be appointed:
- Congressional staff member
- Family member
- Friend or neighbor
- Member of a beneficiary advocacy group
- Member of a provider or supplier advocacy group
- Attorney
- Physician or supplier
How Is an Appointment Made?
Complete the CMS Appointment of Representative form (CMS-1696) or submit a written statement that contains all the following required elements:
- Name, address, and telephone number of the party seeking a representative
- MBI number when the party making the appointment is the beneficiary
- Provider number when the party making the appointment is a provider
- Name, address, and telephone number of the party being appointed as a representative
- A statement that the party authorizing the representative to act on their behalf for the claim at issue
- A statement authorizing disclosure of individually identifying information to the representative (in cases where the representative is not the provider)
- Signature of party making the appointment and the date signed
- Signature of individual accepting the appointment, accompanied by a statement that the individual accepts the appointment, and date signed
A representative must sign the appointment within 30 days of the party’s signature. With one exception, an attorney does not need an acceptance signature.
How Long is an Appointment of Representative Form Valid?
An Appointment of Representative form is good for one year from:
- the date signed by the party making the appointment; or
- the date the appointment is accepted by the representative, whichever is later.
The appointment of representative remains valid for any subsequent levels of appeal. A copy of the appointment should be attached when submitting the next level of appeal unless the beneficiary withdraws the representative’s authority or the beneficiary becomes incapacitated.
The party appointing a representative may revoke the appointment by providing a written statement of revocation to the A/B MAC at any time.
When is an Appointment Not Necessary?
If the requestor is the beneficiary’s legal guardian, surrogate decision maker for an incapacitated beneficiary, or otherwise authorized under state law, no appointment is necessary.
Are Requirements Different if an Attorney is the Representative?
If the person representing the party is an attorney, the attorney is not required to sign the Appointment of Representative form or a written statement. However, the party appointing the attorney must still sign the completed Appointment of Representative form or a written form making the appointment. The A/B MAC must assume that the attorney accepted the appointment within the 30 days.
What Rights Does a Representative Have?
A representative has all the same rights as the person/party they are representing. The representative may submit arguments, evidence or other materials on behalf of the appellant. The representative may obtain information from the A/B MAC regarding the claim or appeal at issue. The representative and the party may participate at all levels of the appeal. Any notice, acknowledgement, or determination letter must be sent to both the party and the representative. The appellant is the addressee with the representative receiving a copy of the notice.
What Are the Responsibilities of the Representative?
The appointment of representative by a party must be made freely and without coercion. The A/B MAC should assume that a representative is not making false or misleading statements, representations, or claims about any material fact affecting any person’s rights.
The representative will have access to confidential information. The A/B MAC must assume that the representative will not disclose personal information except as necessary to pursue the appeal. The representative should not disclose any personal or confidential medical information outside of the appeals process.
A provider or supplier may not charge the beneficiary a fee to represent him/her. A statement to this effect should be included in the right to represent form or the written form.
A representative should keep a completed appointment on file and submit a copy with each claim appealed.
What if the Appointment of Representation Form is Incomplete or Defective and the Represented Party is the Beneficiary?
There are three different scenarios:
- If an individual is attempting to represent a beneficiary and has submitted an incomplete or defective form, the A/B MAC must advise the individual how to complete the appointment. The A/B MAC allows 14-calendar days for a corrected appointment to be submitted. If at the end of the 14 days, no completed form is submitted, the A/B MAC should complete the appeal and notify the beneficiary and any other party to the appeal—but not an unauthorized representative.
- If the A/B MAC has evidence (a signed MSN) that the beneficiary knew of or approved of the submission of the request for a redetermination and the representative does not send a right to representation form, no action is necessary. The appeal will be entered as a beneficiary request, and the A/B MAC should complete the appeal and notify the beneficiary and any other party to the appeal—but not an unauthorized representative.
- If the A/B MAC has evidence that the appointment was not submitted at the request of the beneficiary, the A/B MAC will not conduct the appeal unless confirmation is received from the beneficiary that the request was submitted with his/her approval. In this case, a CMS Appointment of Representative form (CMS-1696) will be requested with the acknowledgement.
What If the Appointment of Representation Form is Incomplete or Defective and the Represented Party is the Provider?
The A/B MAC notifies both the person submitting the appointment and the provider that the appointment is incomplete. The A/B MAC allows 14 days for the corrected/completed appointment to be submitted. It can be submitted by mail or facsimile. If the form is not corrected/completed after the 14 days, the appeal request is dismissed, and the provider and the person submitting the appointment are notified.
Is a Power of Attorney Acceptable as a Valid Appointment?
A valid appointment is treated as a power of attorney by an A/B MAC treats a power of attorney as a valid appointment if all the required elements are present and the power of attorney authorizes the designated person to conduct the beneficiary’s affairs. It can be general or very specific but must at least state the beneficiary’s affairs or the beneficiary’s financial matters.
- A power of attorney is exempt from the one year validity rule.
- A power of attorney may be durable (i.e., surviving after the incapacitation of the beneficiary) or nondurable (i.e., automatically revoked upon the incapacitation of the beneficiary).
What Happens to the Appointment if the Beneficiary Becomes Incapacitated or Dies?
If it is a durable power of attorney that authorizes that designated person to conduct the beneficiary’s affairs or make financial decisions, that representative does not become invalid. If it is a valid appointment or a nondurable appointment, it becomes invalid. The A/B MAC must resolve who has legal authority to act on the behalf of the beneficiary.
Who Can File the Appeal if the Beneficiary is Deceased?
The A/B MAC must obtain proof of one of the following:
- Legal representative of the estate
- A person who has assumed responsibility for settling the beneficiary’s estate (a will or probate court document)
Note: Acceptable legal documentation may vary according to each state. If this is not sent with the appeal request, the A/B MAC must request it. The A/B MAC allows 14 days to obtain this information. If the documentation is not received after 14 days, the A/B MAC must dismiss the appeal request. If the documentation comes in after the allotted time, the A/B MAC must consider good cause for late filing.
What Information Can Be Disclosed to the Representative?
The representative is entitled to receive only information that the party (beneficiary or appellant) would be entitled to receive (i.e., determination letter) and that which is pertinent to the case/claim to which the representative is appointed. Any questions as to what information can be released to a representative should be directed to the party’s respective CMS regional office.
Revised 1/18/2022