Original Medicare (Fee-for-service) Appeals

What’s New

July 20, 2021 - Reminder of Demonstration End Date

As a reminder, all activities related to Qualified Independent Contractor (QIC) Telephone Discussion and Reopening Process Demonstration will be ending December 31, 2021. This includes activities conducted by both the Durable Medical Equipment (DME) and Part A East QIC contractors. We thank you for your interest and participation.

March 9, 2021 – Notice Regarding Court Decision Concerning Certain Appeal Rights for Medicare Beneficiaries

A federal district court issued a Memorandum of Decision dated March 24, 2020 (Alexander v. Azar, Case No. 3:11-cv-1703-MPS, -- F. Supp. 3d --, 2020 WL 1430089 (D. Conn. Mar. 24, 2020), appeal pending, No. 20-1642 (2d Cir.)) and entered a Judgment dated March 26, 2020 in a class action seeking certain appeal rights for Medicare beneficiaries who receive observation services as outpatients. The government has appealed the district court’s judgment, and will post further updates as appropriate if and when there are new developments. Additional information is available in the Downloads section below.

May 7, 2020 – Enhanced Opportunity for Submission of 2^nd Level Appeals, Reconsiderations

Qualified Independent Contractors (QICs) that process 2^nd level Medicare Fee-For-Service (FFS) claim appeals, reconsiderations, on behalf of the Centers for Medicare & Medicaid Services (CMS) have established alternative communication mediums for CMS stakeholders to submit reconsideration requests and related documentation to the QIC. The websites for the respective QIC jurisdictions contain instructions to stakeholders for electronic (e.g., fax or portal) submission of reconsideration requests or documentation. Guidance regarding the options for submitting reconsiderations and related documentation is also summarized by QIC jurisdiction in the table below.

QIC Jurisdiction	Contractor	Options for Submission of 2nd Level Appeals & Related Documentation to the QIC
Part A East	C2C Innovative Solutions, Inc.	Requests can be submitted in writing, via fax to 904-539-4074, or via the Part A East QIC Appeals Portal at https://www.c2cinc.com/QIC-Part-A-East. For beneficiary expedited reconsiderations requests (e.g., service termination denials) following an unfavorable expedited redetermination conducted by a Qualified Improvement Organization, please call 1-855-371-5817.
Part A West	MAXIMUS Federal Services	Requests can be submitted in writing, via the Part A West QIC Appeals Portal at https://qicappeals.cms.gov, or by fax to 585-869-3346. For beneficiary expedited reconsiderations requests (e.g., service termination denials) following an unfavorable expedited redetermination conducted by a Qualified Improvement Organization, please continue to call 1-866-950-6509.
Part B North	C2C Innovative Solutions, Inc.	Requests can be submitted in writing, via fax to 904-539-4081, or via the Part B North QIC Appeals Portal at https://www.c2cinc.com/QIC-Part-B-North.
Part B South	C2C Innovative Solutions, Inc.	Requests can be submitted in writing, via fax to 904-539-4090, or via the Part B South QIC Appeals Portal at https://www.c2cinc.com/QIC-Part-B-South.
Durable Medical Equipment (DME)	MAXIMUS Federal Services	Requests can be submitted in writing, via the DME QIC Appeals Portal at https://qicappeals.cms.gov/, or by fax to 585-869-3314.

Note: implementation of these alternative mechanisms does not preclude CMS stakeholders from ongoing submission of 2^nd level appeals via hard copy mail.

Another ongoing, alternative method to submit electronic 2^nd level Medicare FFS Part A and Home Health and Hospice (HH+H) claim appeal reconsiderations, is through your Medicare Administrative Contractor (MAC) portal. The table below summarizes MACs that currently support electronic 2^nd level Part A and HH+H reconsideration intake automatically routed to the QIC.

MAC Jurisdiction /Contractor	2nd Level Appeal Claim Type Accepted /Applicable States	MAC Provider Portal
JK National Government Services, Inc.	Part A: Connecticut, New York, Maine, Massachusetts, New Hampshire, Rhode Island, Vermont HH+H: Connecticut, Maine, Massachusetts, New Hampshire, Rhode Island, and Vermont	https://connex.ngsmedicare.com/
JM Palmetto GBA, LLC	Part A: North Carolina, South Carolina, Virginia, West Virginia  HH+H: Alabama, Arkansas, Florida, Georgia, Illinois, Indiana, Kentucky, Louisiana, Mississippi, New Mexico, North Carolina, Ohio, Oklahoma, South Carolina, Tennessee, and Texas	https://palmettogba.com/eservices
JJ Palmetto GBA, LLC	Part A: Alabama, Georgia, Tennessee	https://palmettogba.com/eservices
J15 CGS Administrators, LLC	Part A: Kentucky, Ohio HH+H: Delaware, District of Columbia, Colorado, Iowa, Kansas, Maryland, Missouri, Montana, Nebraska, North Dakota, Pennsylvania, South Dakota, Utah, Virginia, West Virginia, and Wyoming	https://www.cgsmedicare.com/myCGS/Index.html

 

Overview - Standard Appeals Process

Once an initial claim determination is made, any party to that initial determination, such as beneficiaries, providers, and suppliers – or their respective appointed representatives – has the right to appeal the Medicare coverage and payment decision. For more information on who is a party, see 42 CFR 405.906.

Section 1869 of the Social Security Act and 42 CFR part 405 subpart I contain the procedures for conducting appeals of claims in Original Medicare (Medicare Part A and Part B).

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

1. First Level of Appeal:        Redetermination by a Medicare Administrative Contractor (MAC)
2. Second Level of Appeal:   Reconsideration by a Qualified Independent Contractor (QIC)
3. Third Level of Appeal:       Decision by the Office of Medicare Hearings and Appeals (OMHA)
4. Fourth Level of Appeal:     Review by the Medicare Appeals Council
5. Fifth Level of Appeal:        Judicial Review in Federal District Court

For detailed information about each level of appeal, use the navigation bar on the left side of this page. A downloadable brochure from the Medicare Learning Network (MLN) designed as a quick reference to the claims appeals process for providers, physicians, and other suppliers can be found in the "Related Links" section below.  To see a diagram (flowchart) of the original Medicare (fee-for-service) standard and expedited appeals process, go to the "Downloads" section below.

Appointment of Representative

A party may appoint any individual, including an attorney, to act as his or her representative during the processing of a claim(s) and /or any claim appeals.  A representative may be appointed at any time during the appeals process.  

There are 2 ways that a party can appoint a representative:

1. Fill out the Appointment of Representative Form (CMS-1696; a link to this form can be found in the "Related Links" section below); or
2. Create a written notice containing all of the elements listed in 42 CFR 405.910.  

The appointment of representative is valid for one year from the date it contains the signatures of both the party and the appointed representative.  A valid appointment of representative may be used multiple times to initiate new appeals on behalf of the party, unless the party provides a written statement of revocation of the representative’s authority. The appointment remains valid for any subsequent levels of appeal on the item/service in question unless the party specifically withdraws the representative’s authority. A detailed explanation on appointing a representative can also be found in the Medicare Claims Processing Manual Publication 100-4, chapter 29 (PDF), section 270.

Expedited Determination Appeals Process (Some Part A claims only)

Home Health Agencies (HHAs), Skilled Nursing Facilities (SNFs), Comprehensive Outpatient Rehabilitation Facilities (CORFs), and Hospices caring for beneficiaries enrolled in Original Medicare are required to notify beneficiaries of their right to an expedited review process when these providers anticipate that Medicare coverage of their services will end before they have finished providing them. Hospitals are also required to notify hospitalized inpatient Original Medicare beneficiaries of their hospital discharge appeal rights and their right to appeal a discharge decision.

For detailed information about the expedited determination appeals process, see the CMS.gov Expedited Determination Beneficiary Notices webpage sections at /Medicare/Medicare-General-Information/BNI/FFS-Expedited-Determination-Notices. For information on hospital discharge appeal rights, refer to /Medicare/Medicare-General-Information/BNI/HospitalDischargeAppealNotices. Applicable regulations can be found at 42 CFR 405 Subpart J—Expedited Determinations and Reconsiderations of Provider Service Terminations, and Procedures for Inpatient Hospital Discharges.