Advisory
Medicare Appeals
Resources on appealing Medicare claims determinations.
Appealing Medicare Claims Determinations
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.
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Orginally established for the beneficiary under the Social Security Act
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Utilized primarily by providers
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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
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Once an initial claim determination is made, providers, Medicare-participating physicians and other suppliers have the right to appeal.
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Physicians and other suppliers who do not take assignment on claims have limited appeal rights.
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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.
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All appeal requests must be made in writing.
Notice of Initial Denial
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For providers, notice of the denial is sent via electronic or paper remittance advice (RA)
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Notice must contain:
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Basis for full or partial denial
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Info on right to a Redetermination
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All applicable claim adjustment reasons & remark codes
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Source of the RA & who may be contacted for more information
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Five Levels in the Appeals Process
Additional Resources
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Medicare Claims Processing Manual, Chapter 29: Apeals of Claims Decisions
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Medicare Appeals Process, brochure, Medicare Learning Network, July 2006
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Medicare Learning Network’s Appeals Educational Web Guide
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Medicare Appeals Information, DHHS, includes all forms and FAQs on appealing appealing a Local Coverage Determination (LCD)
Related Resources
AHA Center for Health Innovation Market Scan