The Five Levels Of Medicare Appeals

Before Appealing

Not every denial needs an appeal. Minor errors such as a wrong modifier or diagnosis code are usually fixed faster through a reopening or a corrected claim. Appeals are for disputes over medical necessity, coverage or coding judgment.

The Five Levels

• Level 1, Redetermination by the MAC: request within 120 days of receiving the initial determination
• Level 2, Reconsideration by a Qualified Independent Contractor: request within 180 days of the redetermination decision
• Level 3, Hearing by an Administrative Law Judge at the Office of Medicare Hearings and Appeals: request within 60 days, and the amount in controversy must meet the annual threshold
• Level 4, Review by the Medicare Appeals Council: request within 60 days of the ALJ decision
• Level 5, Judicial review in federal district court: file within 60 days, subject to a higher amount in controversy threshold

Build The Record Early

Evidence should be submitted at the first two levels. Evidence introduced for the first time at the ALJ level may be excluded unless there is good cause for the late submission. A strong redetermination request includes the complete medical record for the date of service, the applicable LCD or policy, and a short letter that ties the documentation to each coverage requirement.

Track Every Appeal

Log each appeal with its level, filing date, deadline for the next level, and decision. Patterns in the decisions show which documentation issues to fix with providers.