Appealing Denied Medicare Claims: Redetermination, Reconsideration, and ALJ

What You Need to Know

Level 1: Redetermination

The DME MAC conducts redeterminations. However, the DME MAC redetermination specialist reviewing your appeal will not have had any involvement with the original denial. If you have relevant new information or medical evidence, you should include it with your redetermination request. Be aware that if your initial denial resulted from an automated pre-payment review, the DME MAC can assert new grounds for denial - i.e., reasons other than those outlined in the original decision - at the redetermination level.

You must file a redetermination request within 120 days of the Medicare Remittance Advice (RA) or overpayment demand letter. The DME MAC then has 60 days to complete the redetermination, though that can extend to 74 days if the MAC requests additional documentation from you or if you submit additional documentation after filing the redetermination.

Level 2: Reconsideration

If you are dissatisfied with the redetermination outcome, the second level of appeal is a reconsideration by a Qualified Independent Contractor (QIC). If the DME MAC has ruled that the service you provided is medically unnecessary, a panel of physicians and other health professionals will review the claim at reconsideration. You must file your reconsideration request within 180 days of receiving your Medicare Redetermination Notice denying your first-level appeal. The QIC then has 60 days to issue a decision.

Level 3: Administrative Law Judge Hearing

 If the QIC reconsideration does not resolve the issue, the third level of appeal involves a hearing before an Administrative Law Judge. You can only request an ALJ hearing if the remaining amount in controversy is at least $180.

You must make the ALJ hearing request within 60 days of receiving the QIC’s unfavorable decision. The time to an ALJ hearing varies based upon the total number of appeals pending before Medicare's ALJ's. After submitting your ALJ hearing request, you will receive an Acknowledgement Letter, which means your case has been entered into the Office of Medicare Hearings and Appeals' case tracking system. You can check on your appeal's status using the ALJ Appeal Status Information System. ALJ hearings are typically done via conference call. 

What this Means for You

First, it is critical that you understand and comply with the different deadlines for each of the 3 Medicare appeal levels.

Second, as you move from level to level, make sure to update your requests by pointing out what specific information you believe the previous reviewer missed. You know and understand your patient's medical issues far more specifically than a claims reviewer does. They can miss facts that you think are important even when you call them out in your appeal.

Third, if you wind up before an ALJ, thorough preparation is imperative. You cannot effectively advocate for your services and your patient's needs if you try to wing it in front of the ALJ. This means you need to spend significant time reviewing the patient's medical records, all denials, and your responses to those denials in order to put yourself in the best position to succeed.

Lastly, there are two additional levels of appeal - Departmental Appeals Board Review and Federal Court Review - that are not discussed in this article. While neither is widely used, we do want to mention that we have recently seen some Medicare Advantage insurers start requesting Departmental Appeals Board Reviews after the ALJ rules against them. This is a relatively recent development that we are tracking and will continue to report on as more information becomes available.