In Medicare Part B, the provider always submits the Medicare claim to the Medicare carrier. The Medicare Carrier issues its initial determination in a notice to the beneficiary after which an aggrieved beneficiary (patient) may pursue three levels of administrative review, followed by the possibility of filing a federal court case. The rules governing the time lines for submission of appeals and the amount of money that must be at issue must be closely followed.
a. The Medicare Part B Claim: The Medicare Part B provider submits the Medicare claim to the carrier.
b. The Initial Determination: The carrier makes a decision on Medicare coverage, called an Initial Determination. The Medicare carrier sends the Initial Determination to the beneficiary by issuing an MSN or an Explanation of Medicare Benefits, (EOMB). To view MSNs and to obtain more information about these notices, you may go to
www.medicare.gov/Basics/S...otice.asp.
c. The first stage of appeal is a Review: An adverse initial determination is appealed by requesting a review by the carrier.
i. A request for review must be made in writing and forms for this purpose may be found on
www.medicare.gov/Basics/f...fault.asp.
ii. The review request must be filed with the carrier by 120 days after receipt of the MSN or EOMB. There is a 5 day presumption for receipt after the date on which the carrier mailed the MSN or EOMB to the beneficiary.
d. The second stage of appeal is a Carrier Hearing: If the review decision is adverse, the beneficiary may appeal by requesting a Carrier Hearing.
i. The Carrier Hearing must be requested within 180 days of receipt of the adverse review decision.
ii. There must be $100 at issue to take an appeal to a Carrier Hearing.
iii. The Carrier Hearing must be requested in writing and forms for requesting a Carrier Hearing may be found on
www.medicare.gov/Basics/f...fault.asp.
e. The third stage of appeal is an Administrative Law Judge Hearing, (ALJ Hearing): If the Reconsideration decision is adverse, the beneficiary may appeal by requesting an ALJ hearing.
i. The ALJ hearing must be requested within 60 days of receipt of an adverse Reconsideration decision.
ii. The request must be made in writing and forms are available at
www.medicare.gov/Basics/f...fault.asp.
iii. There must be at least $100 at issue in order to appeal a Medicare Part B coverage denial to an Administrative Law Judge.
iv. The ALJ holds a hearing at which the beneficiary is given an opportunity to offer testimony and other relevant evidence to establish that Medicare should have covered the home health care after the date on which the home health agency notified the beneficiary that Medicare coverage would cease. After the hearing, the ALJ issues a decision on Medicare coverage for the beneficiarys hospitalization.
a. The beneficiary can waive the right to a hearing. In that case, the ALJ reviews all of the evidence in the appeal record and issues an on-the-record decision.
v. There are no deadlines in effect for issuance of ALJ decisions and beneficiaries often wait months to receive an ALJ decision
f. The fourth stage of appeal is Departmental Appeal Board Review, (DAB): This is the last administrative stage of a Medicare appeal.
i. DAB review must be requested in writing within 60 days after receipt of an adverse ALJ decision. Forms to request a DAB review are available at www.medicare.gov/.
ii. There must be $ 100 at issue to appeal a case to the DAB.
iii. The beneficiary or representative may submit a written memorandum explaining the case. The DAB does not hold in-person hearings.
iv. The DAB reviews all of the evidence in the Medicare appeal record makes a decision about Medicare Part B coverage for the beneficiarys care and mails it to the beneficiary. There are no deadlines for issuance of a DAB decisions and beneficiaries often wait years to receive a DAB decision.
g. Judicial Review:
i. An adverse DAB decision may be appealed to federal court.
ii. There must be at least $1,000 at issue in order to file suit in federal court.
iii. The court papers must be filed within 60 days of receipt of the adverse DAB decision.
iv. While it is not necessary to retain a lawyer to file a federal court case and the court clerks are generally very helpful to unrepresented litigants, it is advisable to have legal representation in a court case.
III. National Coverage Determinations (NCDs), Local Coverage Determinations, (LCDs) and Local Medical Review Policy (LMRP).
The processes for appealing National Coverage Determinations, Local Coverage Determinations and Local Medical review Policies are addressed in a Health Assistance Partnership Issue Brief that will be published soon and posted on the Health Assistance Partnership, at
www.healthassistancepartnership.org/.
IV. The Medicare and SCHIP Beneficiary Improvement and Protection Act of 2000 (BIPA)
In 2000, Congress substantially revised the Traditional Medicare appeals process. Congress wanted to make the process easier for Medicare beneficiaries to understand and to use. Congress imposed deadlines for Medicare contractors to render decisions on Medicare appeals and provided a process for expedited appeals of certain Medicare decisions in situations in which beneficiaries needed quick decisions about Medicare coverage. Most of these innovations have yet to be implemented and the process described above reflects the current structure of Traditional Medicare appeals.
V. The Medicare Prescription Drug Improvement and Modernization Act of 2003 (HR 1)
The Medicare prescription drug bill that Congress passed was signed into law by the President on December 8, 2003. The new law can be found on the House Ways and Means Committee Web site under Whats New? or at
waysandmeans.house.gov/Sp...section=43
The bill contains changes to certain aspects of the Medicare appeals process. Many of the changes relate to provider appeals. The changes that will affect Medicare beneficiaries are as follows:
a. Medicare notices to beneficiaries about claims and appeals decisions must be clearly written in understandable language. Notices must explain pertinent matters, such as the reason for the denial of coverage, including whether a Local Medical Review Policy was used in reaching a claims decision. MSNs must also summarize the medical evidence considered in making the decision and how to appeal the decision. Congress made these provisions effective on October 1, 2004. (Section 933)
b. A prior determination process: A process will be established by July, 2005, to allow a physician or a beneficiary to ask a Medicare fiscal intermediary or carrier for a decision about Medicare coverage of the physicians service before the service has been provided. A beneficiary must be informed if her physician requests a prior determination of Medicare coverage. Prior determinations will not be not subject to a right of appeal. A beneficiary who disagrees with a prior determination that a service is not covered by Medicare will have to obtain the service and then appeal the Initial Determination that will be issued denying the claim. (Section 93
c. Jurisdictional Amounts: Starting in 2005, the amount in controversy required to reach the Administrative Law Judge stage of a Medicare appeal will increase, as it will be indexed to the medical inflation rate. (Section 940)
d. Timelines for Medicare Appeals: Congress lengthened the deadlines it imposed upon Medicare contractors, QIOs, ALJs and the DAB in the Medicare and Medicaid Beneficiary Improvement and Protection Act of 2000, (BIPA), for making decisions regarding Medicare claims and appeals in the Medicare and Medicaid Beneficiary Improvement and Protection Act of 2000 (BIPA). However, CMS has not yet implanted the BIPA timeframes and Congress did not include in the Medicare prescription drug bill a mandate or timeline for CMS to implement the BIPA appeals provisions.
a. The Medicare Part B Claim: The Medicare Part B provider submits the Medicare claim to the carrier.
b. The Initial Determination: The carrier makes a decision on Medicare coverage, called an Initial Determination. The Medicare carrier sends the Initial Determination to the beneficiary by issuing an MSN or an Explanation of Medicare Benefits, (EOMB). To view MSNs and to obtain more information about these notices, you may go to
www.medicare.gov/Basics/S...otice.asp.
c. The first stage of appeal is a Review: An adverse initial determination is appealed by requesting a review by the carrier.
i. A request for review must be made in writing and forms for this purpose may be found on
www.medicare.gov/Basics/f...fault.asp.
ii. The review request must be filed with the carrier by 120 days after receipt of the MSN or EOMB. There is a 5 day presumption for receipt after the date on which the carrier mailed the MSN or EOMB to the beneficiary.
d. The second stage of appeal is a Carrier Hearing: If the review decision is adverse, the beneficiary may appeal by requesting a Carrier Hearing.
i. The Carrier Hearing must be requested within 180 days of receipt of the adverse review decision.
ii. There must be $100 at issue to take an appeal to a Carrier Hearing.
iii. The Carrier Hearing must be requested in writing and forms for requesting a Carrier Hearing may be found on
www.medicare.gov/Basics/f...fault.asp.
e. The third stage of appeal is an Administrative Law Judge Hearing, (ALJ Hearing): If the Reconsideration decision is adverse, the beneficiary may appeal by requesting an ALJ hearing.
i. The ALJ hearing must be requested within 60 days of receipt of an adverse Reconsideration decision.
ii. The request must be made in writing and forms are available at
www.medicare.gov/Basics/f...fault.asp.
iii. There must be at least $100 at issue in order to appeal a Medicare Part B coverage denial to an Administrative Law Judge.
iv. The ALJ holds a hearing at which the beneficiary is given an opportunity to offer testimony and other relevant evidence to establish that Medicare should have covered the home health care after the date on which the home health agency notified the beneficiary that Medicare coverage would cease. After the hearing, the ALJ issues a decision on Medicare coverage for the beneficiarys hospitalization.
a. The beneficiary can waive the right to a hearing. In that case, the ALJ reviews all of the evidence in the appeal record and issues an on-the-record decision.
v. There are no deadlines in effect for issuance of ALJ decisions and beneficiaries often wait months to receive an ALJ decision
f. The fourth stage of appeal is Departmental Appeal Board Review, (DAB): This is the last administrative stage of a Medicare appeal.
i. DAB review must be requested in writing within 60 days after receipt of an adverse ALJ decision. Forms to request a DAB review are available at www.medicare.gov/.
ii. There must be $ 100 at issue to appeal a case to the DAB.
iii. The beneficiary or representative may submit a written memorandum explaining the case. The DAB does not hold in-person hearings.
iv. The DAB reviews all of the evidence in the Medicare appeal record makes a decision about Medicare Part B coverage for the beneficiarys care and mails it to the beneficiary. There are no deadlines for issuance of a DAB decisions and beneficiaries often wait years to receive a DAB decision.
g. Judicial Review:
i. An adverse DAB decision may be appealed to federal court.
ii. There must be at least $1,000 at issue in order to file suit in federal court.
iii. The court papers must be filed within 60 days of receipt of the adverse DAB decision.
iv. While it is not necessary to retain a lawyer to file a federal court case and the court clerks are generally very helpful to unrepresented litigants, it is advisable to have legal representation in a court case.
III. National Coverage Determinations (NCDs), Local Coverage Determinations, (LCDs) and Local Medical Review Policy (LMRP).
The processes for appealing National Coverage Determinations, Local Coverage Determinations and Local Medical review Policies are addressed in a Health Assistance Partnership Issue Brief that will be published soon and posted on the Health Assistance Partnership, at
www.healthassistancepartnership.org/.
IV. The Medicare and SCHIP Beneficiary Improvement and Protection Act of 2000 (BIPA)
In 2000, Congress substantially revised the Traditional Medicare appeals process. Congress wanted to make the process easier for Medicare beneficiaries to understand and to use. Congress imposed deadlines for Medicare contractors to render decisions on Medicare appeals and provided a process for expedited appeals of certain Medicare decisions in situations in which beneficiaries needed quick decisions about Medicare coverage. Most of these innovations have yet to be implemented and the process described above reflects the current structure of Traditional Medicare appeals.
V. The Medicare Prescription Drug Improvement and Modernization Act of 2003 (HR 1)
The Medicare prescription drug bill that Congress passed was signed into law by the President on December 8, 2003. The new law can be found on the House Ways and Means Committee Web site under Whats New? or at
waysandmeans.house.gov/Sp...section=43
The bill contains changes to certain aspects of the Medicare appeals process. Many of the changes relate to provider appeals. The changes that will affect Medicare beneficiaries are as follows:
a. Medicare notices to beneficiaries about claims and appeals decisions must be clearly written in understandable language. Notices must explain pertinent matters, such as the reason for the denial of coverage, including whether a Local Medical Review Policy was used in reaching a claims decision. MSNs must also summarize the medical evidence considered in making the decision and how to appeal the decision. Congress made these provisions effective on October 1, 2004. (Section 933)
b. A prior determination process: A process will be established by July, 2005, to allow a physician or a beneficiary to ask a Medicare fiscal intermediary or carrier for a decision about Medicare coverage of the physicians service before the service has been provided. A beneficiary must be informed if her physician requests a prior determination of Medicare coverage. Prior determinations will not be not subject to a right of appeal. A beneficiary who disagrees with a prior determination that a service is not covered by Medicare will have to obtain the service and then appeal the Initial Determination that will be issued denying the claim. (Section 93
c. Jurisdictional Amounts: Starting in 2005, the amount in controversy required to reach the Administrative Law Judge stage of a Medicare appeal will increase, as it will be indexed to the medical inflation rate. (Section 940)
d. Timelines for Medicare Appeals: Congress lengthened the deadlines it imposed upon Medicare contractors, QIOs, ALJs and the DAB in the Medicare and Medicaid Beneficiary Improvement and Protection Act of 2000, (BIPA), for making decisions regarding Medicare claims and appeals in the Medicare and Medicaid Beneficiary Improvement and Protection Act of 2000 (BIPA). However, CMS has not yet implanted the BIPA timeframes and Congress did not include in the Medicare prescription drug bill a mandate or timeline for CMS to implement the BIPA appeals provisions.
