Podiatry Coding & Billing Alert

Question: I submitted a claim to my Medicare Administrative Contractor (MAC) for a part B patient, but Medicare denied my claim. I want to appeal this decision. Can you explain the different levels of the appeals process?

Alabama Subscriber

Answer: There are five levels of the Medicare appeals process. Before you can request an appeal, you must have a processed claim that Medicare has either fully or partially denied. The levels of appeals include the following:

• Level 1: Redetermination, which goes through your Medicare Administrative Contractor (MAC). Caution: For a redetermination Level 1 appeal to be considered complete, the provider must include all of the following information: the beneficiary’s name; the Medicare beneficiary number; the requested service; the date of service; and the name and signature of the requesting individual. If all of these elements are not included with your initial Level 1 appeal, your MAC will dismiss the case as incomplete.
• Level 2: Reconsideration, which goes through the qualified independent contractor (QIC). Requests for Level 2 appeals can only be made in writing.
• Level 3: Administrative Law Judge Hearing (ALJ). Requests for Level 3 appeals can be made in writing only. Also, your claim must be worth at least $170 to file a Level 3 appeal.
• Level 4: Medicare Appeals Council Department Appeals Board (DAB). Claims for a Level 4 appeal must also be worth at least $170.
• Level 5: US Federal District Court. Claims for a Level 5 appeal must be worth at least $1,670.