Filing an Appeal

The table below identifies the levels of appeal available to providers and beneficiaries, time limitations and minimum amounts in controversy.

LEVEL/TYPE TIME LIMIT AMOUNT IN CONTROVERSY REQUIRED
(after deductible & co-insurance)
Redetermination Within 120 days of receipt of the notice of initial determination No minimum
Qualified Independent Contractor (QIC) Reconsideration Within 180 days from the date of receipt of the notice of the redetermination No minimum
Administrative Law Judge Hearing (ALJ) Within 60 days after the receipt of the reconsideration notice *For requests filed on or before December 31, 2011, at least $130 remains in controversy. This amount that must remain in controversy for ALJ hearing requests filed on or before December 31, 2011, is $130. This amount will remain the same for calendar year 2012.
Departmental Appeals Board (DAB) Within 60 days from the date of receipt of the ALJ decision No minimum
Judicial Review (Federal District Court) Within 60 days from date of receipt of the Appeals Council decision or declination of review by DAB * For requests filed on or before December 31, 2011, at least $1,300 remains in controversy. For requests filed on or after January 1, 2012, the amount will increase to $1,350.

Each Appeal request must contain the following information. Appeal requests will be dismissed if any of this information is missing.

  • Beneficiary name;
  • Medicare Health Insurance Claim (HIC) number;
  • Name and address of provider of service;
  • Date(s) of service for which the initial determination was issued (dates must be reported in a manner that agrees with the Medicare claims filing instructions; ranges of dates are acceptable only if a range of dates is properly reportable on the Medicare claim form);
  • Which item(s), if any, and/or service(s) are at issue in the appeal;
  • Signature of the appellant

In addition, the Claims Appeals Department highly recommends the following information to be included in the Appeal request:

  • Provider facility name with contact information.
  • Provider facility phone number.
  • Appeals requests submitted on provider letterhead.

NOTE: The provider is responsible for submitting ALL documentation to support the denied services at the time of the Appeal request.

Please forward your Appeal request to the address below. If you send them to any other address or via certified mail we cannot guarantee that they will arrive in our department timely.

Iowa
Medicare Part A - MAC J5 Iowa
Attention: Medicare Appeals
PO Box 7665
Madison WI 53707-7665

Kansas
Medicare Part A - MAC J5 Kansas
Attention: Medicare Appeals
PO Box 7576
Madison WI 53707-7576

Missouri
Medicare Part A - MAC J5 Missouri
Attention: Medicare Appeals
PO Box 8890
Madison WI 53707-8890

Nebraska
Medicare Part A - MAC J5 Nebraska
Attention: Medicare Appeals
PO Box 8799
Madison WI 53708-8799

You may contact the Appeals department at the toll-free number below:

1-866-518-3298

Appeal Request Template

An Appeal Request template has been developed to provide a more efficient, streamlined avenue for you to submit appeal requests. This template includes all of the relevant information necessary for submitting a complete appeal request. This template has been revised and is effective May 1, 2005.

You can copy this template to your facility letterhead, or print the template from the Appeals page on our website. You can begin to use this template immediately.

Use of this template will help to insure all required information is present and that the requests are handled more efficiently. You are not required to utilize this template; however, we would strongly urge you to consider incorporating it into your appeal process.

Reconsideration Request Template

A Reconsideration Request Form has been developed to provide a more efficient, streamlined avenue for you to submit a request for the Second Level of Appeal which is a Qualified Independent Contractor (QIC) Reconsideration. The Reconsideration Request Form, with the appropriate QIC address already completed, makes up the last page of the Redetermination Decision letter.

The Reconsideration Request Template can be used, in cases, where, for some reason, the original Reconsideration Request Form cannot be located.

Documentation Requirements

The provider is responsible for submitting all necessary documentation to support their appeals request. Additional documentation will not be requested.

For beneficiary initiated appeals, when necessary documentation has not been submitted, the provider will be contacted via letter requesting they submit the required documentation. If the additional documentation, that was requested, is not received within 14 calendar days, the review will be conducted based on the information in the file. Providers are responsible for providing all the information required in order to adjudicate the claim(s) at issue.

Page Last Updated: Thursday, 22-Dec-2011 10:37:15 CST