Medicare Appeals - The Importance of Getting It to the Right Place at the Right Time!

Over the past year, we at the Qualified Independent Contractor (QIC) Part B North (the processor of second level appeals or reconsiderations) have consistently made what we consider to be a high rate of dismissal decisions. Based on our analysis, the driving factor in this high rate is that appellants, primarily providers and suppliers, request reconsideration when a redetermination (first level appeal performed by the Medicare Administrative Contractor (MAC) having processed the original claim) has not been completed.

While often the cause appears to be simply confusion over the steps of the appeals process and the parties involved, we have also noted that some providers/supplies are confusing written and telephone inquiry responses from the MAC with official redetermination decisions. In accordance with current instructions, contractors are required to issue a written notice of redetermination. If you disagree with this decision, you may then file an appeal in writing with the QIC

Please remember...

  • You have 120 days from the date of receipt of the Remittance Advice to request a redetermination. You do not get extra days if you send it to the wrong entity (i.e. if you send it to the QIC and subsequently receive a dismissal for no redetermination, the 120 day clock is still ticking against the original claim process date).
  • The Medicare Redetermination Notice (MRN) should specifically reference the date of the original decision, state a clear decision of favorable, partially favorable, unfavorable or dismissed, and advise of any further appeal rights with the QIC's address. Please review the entire MRN carefully.
  • Your request for a second level appeal, a reconsideration, should be sent directly to the QIC at the address in the MRN, within 180 days of receipt of the notice. It is helpful if you include a copy of the redetermination decision.

Lastly, please be sure your request details specifically all the claims you are requesting an appeal on, the Beneficiary's name, the Medicare Health Insurance claim number, the dates of service at issue, the services at issue, your reason for appealing, the name and signature of the party or representative of the party, and the name of the contractor that made the redetermination.

Page Last Updated: Thursday, 15-Dec-2011 12:09:32 CST