Standard Appeals Process

Once an initial claim determination is made, beneficiaries, providers, and suppliers have the right to appeal Medicare coverage and payment decisions.

There are five levels in the Medicare Part A and Part B appeals process. The levels are:

First Level of Appeal:    Redetermination by a Medicare carrier, fiscal intermediary (FI), or Medicare Administrative Contractor (MAC).

Second Level of Appeal: Reconsideration by a Qualified Independent Contractor (QIC)

Third Level of Appeal:   Hearing by an Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals

Fourth Level of Appeal: Review by the Medicare Appeals Council

Fifth Level of Appeal:    Judicial Review in Federal District Court

“Medicare excludes payments for all treatment not necessary, but does not require payment for all necessary treatments.”  Goodman v. Sullivan, 891 F.2d 449, 451 (2nd Cir.1989).  

“The prohibitory language of § 1395y(a)(1)(A), which bars benefits for services ‘not reasonable and necessary’ for diagnosis or treatment, is not reasonably interpreted as an affirmative mandate to extend coverage to all necessary services.”  Goodman 891 F.2d 449 at 450.