Advisories
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
Member Advisory: The Medicare Appeals Process (June 14, 2012)Regulatory Advisory: The Medicare Appeals Process (March 27, 2009)
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
- Medicare Claims Processing Manual, Chapter 29: Apeals of Claims Decisions
- Medicare Appeals Process, brochure, Medicare Learning Network, July 2006
- Medicare Learning Network’s Appeals Educational Web Guide
- Medicare Appeals Information, DHHS, includes all forms and FAQs on appealing appealing a Local Coverage Determination (LCD)
Related Resources
Letters/Comments