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Healthcare providers billing for drug services must consider the drug and dosage form that was provided to the patient, the patient's medical record, the coding requirements of each health insurer, and best coding practices. Billing and coding guidance provided under this heading does not provide a guarantee of reimbursement and should be considered together with all applicable guidance and standards.

Medicare Part B Appeals Process

Medicare Part B Fee-for-Service Appeals Process
  Appeal Level Time Limit For
Filing Request		 Amount in
Controversy
(AIC) (2010)		 Reviewer
Employed By		 Reviewer Must
Render Decision
Generally Within1
  vertical rule   vertical rule   vertical rule   vertical rule  
1. Redetermination 120 days* from date of the
notice from Medicare that
the claim has been denied		 No minimum Part B contractor 60 days
2. Reconsideration 180 days* from date
of receipt of the
redetermination		 No minimum Qualified Independent
Contractor (QIC)		 60 days
3. ALJ Hearing 60 days* from the date
of receipt of the
reconsideration		 At least $130‡
remains in
controversy†		 Department of Health
and Human Services		 90 days
4. DAB Review 60 days* from the date
of receipt of the ALJ
hearing decision		 No minimum Department of Health
and Human Services		 90 days
5. Federal Court Review 60 days* from the date
of receipt of DAB decision
or declination of review
by DAB		 At least $1260‡
remains in
controversy†		 Federal Courts No deadline

* The contractor must allow 5 additional days beyond the time limit for mail delivery, or longer if there is evidence that the mail delivery was longer than 5 days. Time limits may also be extended if good cause for late filing is shown, and is not routinely granted.

† The dollar amount in controversy increases annually by the amount of the consumer price index for all urban consumers (U.S. City average). Revised dollar thresholds are announced by the Centers for Medicare and Medicaid Services.

‡ Amount in controversy 2010.

Medicare has a formal appeals process that is relatively easy to initiate but must be managed carefully to ensure that the appeal is properly prepared and that timely filing deadlines are not missed. Many non-Medicare health insurers follow similar procedures.

There are currently five levels of Medicare Part B appeals2:

  • Level 1: Redetermination
  • Level 2: Reconsideration
  • Level 3: Administrative Law Judge (ALJ) Hearing
  • Level 4: Departmental Appeals Board (DAB) Hearing
  • Level 5: Federal District Court Hearing

Each level of appeal must be completed before you are eligible to advance to the next level. In addition, there are time and dollar thresholds that must be met.

See FAQs about Medicare Part B

For more information on Medicare Part B appeals, view the Medicare Part B Fee-for-Service Appeals Process

Reference:

  1. Centers for Medicare & Medicaid Services. The Medicare Appeals Process. Available at:
    http://www.cms.hhs.gov/MLNProducts/downloads/MedicareAppealsProcess.pdf Accessed March 17, 2010.
  2. Centers for Medicare & Medicaid Services. Medicare claims processing manual. Available at:
    http://www.cms.hhs.gov/Manuals/IOM/itemdetail.asp?filterType=none&filterByDID=-%2099&sortByDID=1&sortOrder=ascending&itemID=CMS018912. Accessed March 17, 2010.

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