Fourth-Level Appeal

Medicare Appeals Council Review

If any party to the Administrative Law Judge (ALJ) hearing is dissatisfied with the ALJ’s decision, the party may request a review by the Medicare Appeals Council. There are no requirements regarding the amount of money in controversy. The Medicare Appeals Council review ALJ decision on it’s own Motion

Request for Medicare Appeals Council Review

The request for Medicare Appeals Council review must be submitted in writing within 60 days of receipt of the ALJ’s decision or dismissal, and must specify the issues and findings that are being contested.

Refer to the ALJ decision for details regarding the procedures to follow when filing a request for Medicare Appeals Council review.

Supporting Documentation

No additional documentation unless requested by the Medicare Appeals Council.

Decision Notification

Medicare Appeals Council review is de novo (A trial de novo is a new trial of a case).

In general, the Appeals Council will issue a decision within 90 days of receipt of a request for review. That timeframe may be extended for various reasons, including but not limited to, the case being escalated from an ALJ hearing.

If the Appeals Council does not issue a decision within the applicable time frame, the appellant may ask the Medicare Appeals Council to escalate the case to Judicial Review in the District Court.

Section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) enacted numerous contracting reforms that can impact the claims audit and appeals processes. Check often for new developments: Medicare Contracting Reform Updates




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