All about Medicare - 3

Know about Medicare - Part 3

Medicare Appeals Process


After a claim is processed, Medicare sends the EOBs to the providers determining payment or denial. If the provider feels that the denial or payment is incorrect, a request can be made for review of a claim. A review is another look at the claim. The request for review must be made in writing within 6 months from the date of the EOB. Some Medicare carriers have the facility of telephonic appeal that can be explored. In the case of written request for review, the following documents should be sent to the carrier: Copy of EOB, the claim and medical records. A covering letter explaining the need for review would be helpful. The review will be conducted by a completely different team which did not take part in the original processing of the claim. It is purely based on the documentation sent for review. The determination is made within 45 days from the receipt of the request for review and the decision whether favorable or unfavorable is notified to the provider. If the provider is still not satisfied with the decision, he goes in for a fair hearing.

Fair Hearing

The next step in the appeals process is a Fair Hearing. Fair Hearing can be requested if the disputed amount is at least $100 and not later than 6 months of the review determination. The amount represents the amount that should have been paid according to the provider and not the difference amount. Also the amount may not be of a single claim. It can be more than one claim too. A covering letter with the additional documents as sent for appeal is required for this too. The hearing officer should acknowledge the provider’s request within 2 weeks of receipt. There are three modes of hearing:

In-person hearing wherein the provider or his representative appears before the hearing officer in person on the designated date and time notified by the hearing officer and answers questions raised by the hearing officer and produces documentary evidence required by the hearing officer. The hearing officer is a neutral person appointed by the carrier and is aware of all Medicare rules and regulations.

Telephone hearing wherein questions raised by the hearing officer is answered over phone. This is less time consuming.

On-the-record decisions wherein the decision is based on past information and new information presented by the practice in writing. The Hearing officer will inform decision to the provider’s office in writing within 30 days of the request for hearing. If the provider is still not satisfied with the decision, he goes to the Federal Administrative Law Judge.

Federal Administrative Law Judge.

These Judges are lawyers who work for the Social Security Administration. Here the disputed amount should be atleast $500. The providers should send a letter within 60 days of the hearing decision to the carrier or the local Social Security office requesting ALJ’s hearing. The process will the same as that of the hearing officer. The decision should be made and notified to the provider within 15 days of the receipt of request. If the decision is still unfavorable to the provider, the provider can send his request within 60 days to the appeals council.

Appeals Council

This is the last resort. This is done by the Federal District Court and the disputed amount should be at least $1000. Here both the provider and his attorney are requested to appear before the court. The decision made will be final and binding on both the parties.

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