By: Zach Simpson
There might be times when Medicare denies coverage for an item, service, or test that you or your company provided. In the event this occurs you have the right to formally disagree wit the decision and encourage Medicare to change it. Therefore, understanding the appeals process for Medicare claims is vital for all providers. The aim of this article is to give providers a better understanding of the five (5) levels of the Medicare Appeal process, and what must occur at each level.
The Medicare Fee-For-Service (FFS) has five levels in the claims appeal process:
Level 1 – Redetermination by a Medicare Administrative Contractor (MAC)
Level 2 – Reconsideration by a Qualified Independent Contractor (QIC)
Level 3 – Disposition by Office of Medicare Hearings and Appeals (OMHA)
Level 4 – Review by the Medicare Appeals Council (Council)
Level 5 – Judicial review in U.S. District Courtread more