What If Medicare Denies My Claim?



Level 1 – Re-determination

The patient needs to submit the CMS-20027 form within 120 days of the initial determination. The re-determination division then has 60 days to respond to the request.

Level 2 – Qualified Independent Contractor

The CMS-20033 need to be submitted within 180 days of the re-determination decision. The Qualified Independent Contractor has 60 days to make a decision. The patients can request 14-day extensions each time they submit new documentation in support of their appeal.

Level 3 – Administrative Law Judge

Medicare decisions can be reviewed by an Administrative Law Judge (ALJ). By this point, the claim must be for a minimum of $120 and the patient has 60 days to submit the appeal. From the point, the ALJ has 90 days to submit a decision. If, however, there is no decision from a Qualified Independent Contract, then the ALJ can take up to 180 days. Since there are only 4 offices nationwide, the vast majority of disputes are heard via teleconference or over the telephone.

Level 4 – Medicare Appeals Council

Again, the Medicare recipient has 60 days to submit an appeal and the Council has 90 days to review all the documents and provide a decision.

Level 5 – Federal Court

This final step is the most drastic of the appeal processes and the claim must be at least $1,220. The claim must be submitted within 60 days of the Medicare Appeals Council decision.

As this can be a laborious and time-intensive process, it is recommended that any Medicare recipient making an appeal should seek out legal advice once they reach Level 3. If they proceeded, they should also have a lawyer for Stages 4 and 5 as well.



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