Appeals

Filing an Appeal

The chart below lists the various levels of appeals available, including time limitations for filing and, where applicable, the minimum amount-in-controversy requirement. If a decision was not issued at a previous level, appeals to higher levels will usually be dismissed back to the appropriate prior level for review.

	Level I	Level II- NEW	Level III	Level IV	Level V
Part A & Part B	Redetermination (fiscal intermediary)	Reconsideration (Qualified Independent Contractor (i.e. QIC)	Administrative Law Judge (ALJ)	Department of 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 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)	At least $100 remains in controversy.For requests filed on or after January 1, 2008, at least $120 remainsin controversy.	No minimum (None)	For requests filed on or after January 1,2008, at least $1,180 remains in controversy.

If the denial was made by Medical Review, timeliness for filing an appeal request is calculated using the date on the Remittance Advice. When the services were denied as the result of a Comprehensive Medical Review, the date of the decision letter is used to calculate the time limit for filing an appeal. Redetermination requests received after the time frame listed above are considered untimely and will be dismissed. (The date of receipt of any decision letter is considered to be 5 days after the date of the letter unless evidence to the contrary is also sent.)

When sending appeal requests in certified or overnight envelopes, the first name(s) and last initial(s) of the beneficiary(s), along with the respective date(s) of service for the request(s) enclosed in the package, must be documented on the envelope's receipt. This will be used to establish timeliness for specific cases should questions arise.

** At the time of the Appeals request, the provider is responsible for submitting ALL of the documentation needed to support its claim to payment. **

PLEASE NOTE: Any evidence that was not submitted at the redetermination level must be submitted to the QIC at the reconsideration level. It should accompany the request for reconsideration. All evidence, including any not mentioned in the redetermination decision letter, must be presented before the reconsideration decision is issued.

If all evidence is not submitted, new evidence cannot be submitted in subsequent appeals unless good cause can be demonstrated for not presenting the evidence to the QIC.

At least one (1) of the following must be submitted for all Appeal requests:

A signed letter requesting an appeal/redetermination and stating dissatisfaction with the initial determination; or
A signed Request for Redetermination, CMS-20027 form

NOTE: A Provider Inquiry/Adjustment form is not appropriate for requesting an Appeal.

Each appeal request should contain the following:

Beneficiary's name, clearly written
Health Insurance Claim Number (with alpha characters)
Provider name and number
Dates of service of the claim(s) that contain partially or fully denied services
Requester's legible signature
The date of the signature

-All signatures must be original, not a copy or a typed signature.

NOTE: An appeal request signed by the provider and the beneficiary is processed as a beneficiary request. The beneficiary's signature takes precedence and all correspondence will be addressed to the beneficiary.