Medicare Conditional Payment Appeals Process

Before any appeal begins, you have to have a final demand letter from Medicare. This is only generated once Medicare learns of a settlement, judgment or award involving its beneficiary. Review the final demand itemization carefully. Even if you disagree with the amount, you are likely well-served to make payment under protest to avoid interest from accruing. Here is your path to appeal this final demand determination.

If you disagree with Medicare's final demand figure, you would first ask Medicare for a redetermination.   A redetermination is a review of the claim by Medicare Administrative Contractor personnel not involved in the initial claim determination.  The appellant (the individual filing the appeal) has 120 days from the date of receipt of the initial claim determination (aka Final Demand Letter) to file a redetermination request.   The appellant should include with their redetermination request any and all documentation that supports their argument against the previous decision.  Generally, a decision is sent within 60 days of receipt of the request for redetermination. The decision will contain detailed information on further appeals rights, where applicable. 

Any party to the redetermination that is dissatisfied with the decision may request a reconsideration. A reconsideration is an independent review of the administrative record, including the initial determination and redetermination, by a Qualified Independent Contractor (QIC).  The appellant (the individual filing the appeal) has 180 days from the date of receipt of the redetermination decision to file a reconsideration request.   The request should clearly explain why the appellant disagrees with the redetermination, and be accompanied by any evidence or allegations of fact or law related to the issue(s) in dispute.  Generally, the QIC will send this decision to all parties within 60 days of receipt of the request for reconsideration.  The reconsideration decision will contain detailed information on further appeals rights, where applicable. 

 Any party that is dissatisfied with the Qualified Independent Contractor’s (QIC's) reconsideration decision may request a hearing before an Administrative Law Judge (ALJ).  A request for an ALJ hearing must be filed within 60 days of receipt of the reconsideration decision.   In order to request a hearing by an ALJ, the amount remaining in controversy must meet the threshold requirement. This amount is recalculated each year and may change.  ALJ hearings are held by telephone, unless the ALJ finds good cause for an appearance by other means such as video teleconference (VTC) or in person.   When a request for an ALJ hearing is filed after a QIC has issued a reconsideration, an ALJ or attorney adjudicator issues a decision, dismissal order, or remand to the QIC, as appropriate, no later than the end of the 90 calendar day period beginning on the date the request for hearing is received by the office specified in the QIC's notice of reconsideration, unless the 90 calendar day period has been extended.  

Any party that is dissatisfied with Office of Medicare Hearings and Appeals (OMHA) decision or dismissal may request a review by the Medicare Appeals Council (the Council).   A request for Council review must be filed with the Council, a component of the Department of Health & Human Services, Departmental Appeals Board, within 60 days of receipt of the notice of OMHA's decision or dismissal.  There is no requirement regarding the amount of money in controversy for Council review.   The request for review must be made in writing and must specify the parts of the decision or action that the party disagrees with, why they disagree. The appellant should include a copy of the disputed decision with the appeal.  

 Any party that is dissatisfied with the Medicare Appeals Council’s (the Council) decision may request review in Federal court.   A party may file an action in a Federal district court within 60 calendar days after the date it receives notice of the Council's decision. Only after all previous five (5) steps have been completed does a party have standing to bring an action against Medicare in U.S. Federal Court. Judicial opinions provide multiple examples of cases dismissed for lack of standing. In order to request judicial review in Federal court, the amount remaining in controversy must meet the threshold requirement. This amount is recalculated each year and may change.