Filing an Appeal - MAC Part A
The table below identifies the levels of appeal available to providers and beneficiaries, time limitations and minimum amounts in controversy.
Appeals levels January 1, 2008 and after - Part A Inpatient and Part B Outpatient
Level One - Redetermination
Time Limits - 120 days from the Remittance Advice date
Amount in Controversy - None
Level Two - *Reconsideration
Time Limits - 180 days from the Redetermination date
Amount in Controversy - None
Level Three - Administrative Law Judge (ALJ)
Time Limits - 60 days from reconsideration decision notice date
Amount in Controversy - Requests made before 01/01/2008: $110
Requests made on or after 01/01/2008: $120
Level Four - Departmental Appeals Board (DAB)
Time Limits - 60 days from ALJ decision date
Amount in Controversy - None
Civil Action - US District Court
Time Limits - 60 days from DAB decision date
Amount in Controversy - Before 01/01/2008: $1,130
On or after 01/01/2008: $1,180
* Reconsideration requests must be submitted to the appropriate Qualified Independent Contractor (QIC). Please refer to the redetermination notice for further information.
Each Appeal request must contain the following information. Appeal requests will be dismissed if any of this information is missing.
- Beneficiary name;
- Medicare Health Insurance Claim (HIC) number;
- Name and address of provider of service;
- Date(s) of service for which the initial determination was issued (dates must be reported in a manner that agrees with the Medicare claims filing instructions; ranges of dates are acceptable only if a range of dates is properly reportable on the Medicare claim form);
- Which item(s), if any, and/or service(s) are at issue in the appeal;
- Signature of the appellant
In addition, the Claims Appeals Department highly recommends the following information to be included in the Appeal request:
- Provider facility name with contact information.
- Provider facility phone number.
- Appeals requests submitted on provider letterhead.
NOTE: The provider is responsible for submitting ALL documentation to support the denied services at the time of the Appeal request.
Please forward your Appeal request to the address below. If you send them to any other address or via certified mail we cannot guarantee that they will arrive in our department timely.
Nebraska
WPS
P.O. Box 8799
Madison, WI 53708-8799
Kansas
WPS
P.O. Box 7576
Madison, WI 53707-7576
You may contact the Appeals department at the toll-free number below:
1-866-518-3298
Appeal Request Template
An Appeal Request template has been developed to provide a more efficient, streamlined avenue for you to submit appeal requests. This template includes all of the relevant information necessary for submitting a complete appeal request. This template has been revised and is effective May 1, 2005.
You can copy this template to your facility letterhead, or print the template from the Appeals page on our website. You can begin to use this template immediately.
Use of this template will help to insure all required information is present and that the requests are handled more efficiently. You are not required to utilize this template; however, we would strongly urge you to consider incorporating it into your appeal process.
Reconsideration Request Template
A Reconsideration Request Form has been developed to provide a more efficient, streamlined avenue for you to submit a request for the Second Level of Appeal which is a Qualified Independent Contractor (QIC) Reconsideration. The Reconsideration Request Form, with the appropriate QIC address already completed, makes up the last page of the Redetermination Decision letter.
The Reconsideration Request Template can be used, in cases, where, for some reason, the original Reconsideration Request Form cannot be located.
Documentation Requirements
The provider is responsible for submitting all necessary documentation to support their appeals request. Additional documentation will not be requested.
For beneficiary initiated appeals, when necessary documentation has not been submitted, the provider will be contacted via letter requesting they submit the required documentation. If the additional documentation, that was requested, is not received within 14 calendar days, the review will be conducted based on the information in the file. Providers are responsible for providing all the information required in order to adjudicate the claim(s) at issue.
Page Last Updated: Thursday, 13-Nov-2008 09:00:39 CST
