Appeal Rights

According to the Medicare Claims Processing Manual Chapter 29 - Appeals of Claims DecisionsAdobe Portable Format document:

The provider may appeal an initial determination only if:

  • Items or services are not covered because they are not reasonable and necessary or constitute custodial care;
  • Neither the beneficiary nor the provider knew or could reasonably have been expected to know that the services were not covered; and
  • The beneficiary has been found not liable for the cost of the service(s) under limitation of liability or indicates in writing that he/she does not intend to request reconsideration of the Fiscal Intermediary's (FIs) initial determination.
  • If the beneficiary appeals the FIs initial determination, the provider is made a party to the appeal.

Beneficiaries are almost always considered parties to a Medicare determination, as they are entitled to appeal any determination related to their claim. The beneficiary's appeal rights are on the back of the Explanation of Medicare Benefits (EOMB), if they are in the Original Medicare Plan, or on the Medicare Summary Notice (MSN) that is mailed from a contractor that handles bills for Medicare.

Page Last Updated: Tuesday, 20-Sep-2011 08:47:25 CDT