Medicare appeal process

Appealing Medicare Decisions

Beneficiaries, physicians and other providers (on assigned claims) dissatisfied with a determination on their Part B claim have the right to appeal the determination.

Who can appeal?

Any of the following persons, entities are parties to an appeal of a claim for items or services payable under Part B:

• Beneficiary;

• A participating physician or other supplier (i.e. one who has agreed to take assignment on all items or services payable on behalf of a Medicare beneficiary);

• A non-participating physician or other supplier taking assignment for a specific item or service as a party status for that item or service;

• A non-participating physician not taking assignment, but potentially responsible for making a refund to the beneficiary under Section 1842(1) (1) of the Social Security Act, has party status for that claim. Section 1842(1)(1) gives party status to non-participating physicians, for example, where (1) a claim for an item or service is denied as not being reasonable and
necessary under Section 1862 (a)(1); (2)where the supplier has already collected payment from the beneficiary for the item or service in question; and (3) where the physician is claiming that he/she did not know and could not reasonably expected to know that the item or service would be denied as not being reasonable and necessary under Section 1862 (a)(1); A
Medicaid State agency, or a party authorized to act on behalf of the State.

The Medicare Part B Appeals Process consists of five levels:

1. Re-determination
2. Reconsideration by QIC
3. Administrative Law Judge (ALJ) Hearing
4. Departmental Appeal Board (DAB)
5. Federal Court

Each level of the appeals process must be completed before moving to the next level.

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