Medicare Appeals Process - TIPS

The 5 Levels of Appeals

Medicare has five levels of appeals for Part A and Part B once an initial claim determination is made.

MA130: If you get this message on your RA it just means you have incomplete information, you do not need to request a Reopening or Appeal. Submit a new claim with the complete information. 

Reopening: (this is not an appeal level) Minor errors or omissions: Diagnosis change/addition, Change date of service, Modifier issues KH KI KJ KX RR or units changes.

1 year from date of service , no threshold amount. Call, Fax or Mail. The DME Reopening form should be used. 

Appeal Levels 1-5

#1. Redetermination: 120 days from the date of receipt of the initial claim (R, No monetary threshold, Fax or Mail

#2. Reconsideration: 180 days from date of receipt of redetermination decision, No monetary threshold, Mail. ( call your MAC for address)

#3. Administrative Law Judge: 60 days from date of receipt of reconsideration decision, At least $130.00 remains in controversy , Instructions included in reconsideration instructions.

#4. Departmental Appeals Board: 60 days from date of receipt of ALJ decision, No monetary threshold, Instruction included in ALJ decision.

#5. Federal Court Review: 60 days from date of receipt of DAB decision, At least $1,260.00 remains in controversy, Instructions included in DAB decision.