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.

  • 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

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


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

 


 

Additional Resources

 

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