This resource provides an overview of the Medicare Part A and Part B administrative appeals process available to beneficiaries, providers, physicians and other suppliers who provide services and supplies to Medicare beneficiaries.

• Orginally established for the beneficiary under the Social Security Act
• Utilized primarily by providers
• The rate of reversal during the appeal process in the mid 1990’s was high enough to cause “concern” for CMS and its contractors

AHA Advisories

Member Advisory: The Medicare Appeals Process (June 14, 2012)

Regulatory Advisory: The Medicare Appeals Process (March 27, 2009)

The Right to Appeal

• Once an initial claim determination is made, providers, Medicare-participating physicians and other suppliers have the right to appeal.
• Physicians and other suppliers who do not take assignment on claims have limited appeal rights.
• Beneficiaries may transfer their appeal rights to non-participating physicians, or other suppliers who provide the items or services and do not otherwise have appeal rights by submitting a completed Form CMS-20031.
• All appeal requests must be made in writing.

Notice of Initial Denial

• For providers, notice of the denial is sent via electronic or paper remittance advice (RA)
• Notice must contain:
  • Basis for full or partial denial
  • Info on right to a Redetermination
  • All applicable claim adjustment reasons & remark codes
  • Source of the RA & who may be contacted for more information

Five Levels in the Appeals Process

• Redetermination
• Reconsideration
• Hearing by an Administrative Law Judge
• Review by the Medicare Appeals Council
• Judicial Review in U.S. District Court

Additional Resources

• Legislative authority and regulatory development
• Medicare Claims Processing Manual, Chapter 29: Apeals of Claims Decisions
• Flowchart: Comparison of Current and BIPA 521 Fee-For-Service Appeals Processes, CMS
• Medicare Appeals Process, brochure, Medicare Learning Network, July 2006
• Medicare Learning Network’s Appeals Educational Web Guide
• Medicare Appeals Information, DHHS, includes all forms and FAQs on appealing appealing a Local Coverage Determination (LCD)