Pulmonology Coding Alert

Question: We filed a claim for a Medicare Part B patient with our Medicare Administrative Contractor (MAC). However, Medicare denied the claim. We would like to contest the rejection.

Could you break down the levels of the Medicare appeals process?

Washington Subscriber

Answer: The Medicare appeals process consists of five stages. Prior to initiating an appeal, you need a claim that Medicare has either completely or partially rejected. The stages 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 the following information: the beneficiary’s name, the Medicare beneficiary number, the requested service, the date of service, the name and signature of the requesting individual.

If every one 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) with the Office of Medicare Hearings and Appeals (OMHA). Requests for Level 3 appeals can be made in writing only. Also, the amount in controversy must be at least $180 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 $180.

Level 5: U.S. Federal District Court. Claims for a Level 5 appeal must be worth at least $1,840.

For more information on the Medicare appeals process, visit: https://www.cms.gov/medicare/appeals-grievances/fee-for-service.