Medicare Part B
All providers may appeal the initial determination made by the Recovery Audit Contractors, either informally or formally. The informal process involves appealing directly to the contractor within 15 days of receiving a notice to recoup an overpayment from the RAC. The formal process is more complex and involves a five-step process. To determine which process to use, CMS has created some information to assist you in comparing the different options.
Formal appeals process
For an overview of the formal appeals process, view the graphic representation of the process.
First Level Appeal: Redetermination
- Once you receive the initial determination, you have 120 days to file a written appeal to your Medicare contractor. If you do not file within the first 30 days, Medicare may begin the recoupment process. Interest begins accruing during this time as well.
- To appeal a denial, use the Medicare Redetermination Request Form.
- The Medicare contractor will have 60 days to investigate the RAC decision to determine if its findings are justified.
- If the initial determination is overturned, the Medicare contractor will include any payment owed as a result of recoupment along with the redetermination letter.
- If your appeal is denied, you will receive a letter of explanation from the Medicare contractor.
|Timeframe for Medicare Recoupment Process After the First Demand Letter TimeFrame||Medicare Contractor||Provider|
|Day 1||Date of demand letter (date demand letter mailed)||Provider receives notification by first class mail of overpayment determination|
|Day 1 to 15||Day 15 deadline for rebuttal request. No recoupment occurs||Provider must submit a statement within 15 days from the date of demand letter|
|Day 1 to 40||No recoupment occurs||Provider can appeal and potentially limit recoupment from occurring|
|Day 41||Recoupment begins||Provider can appeal and potentially stop recoupment|
Second Level Appeal: Reconsideration
- You have 180 days to file a request for reconsideration once the original appeal has been denied.
- To file a request for reconsideration, use the Medicare Reconsideration Request Form. This request is sent to a Qualified Independent Contractor (QIC), rather than to your Medicare contractor. Along with the form, you should include all of your concerns, issues and evidence to help support your appeal.
- Once received, the QIC has 60 days to make a decision.
|Timeframe for Medicare Recoupment Process After Redetermination Timeframe||Medicare Contractor||Provider|
|Day 60 following revised notice of overpayment following redetermination||Date reconsideration request is stamped in mailroom, or payment received from the revised overpayment notice||Provider must pay overpayment or must have submitted request for 2nd level appeal|
|Day 61-75||Recoupment could begin on the 61st day||Provider appeals or pays|
|Day 76||Recoupment begins or resumes||Provider can still appeal. Recoupment stops on date receipt of appeal|
Third Level Appeal: Office of Medicare Hearing and Appeals (OMHA)
- If the QIC rejects your appeal, you can request a hearing by filing a request for Medicare hearing by an Administrative Law Judge (ALJ) within 60 days of receipt of the QIC’s denial.
- At this level, the appeal will no longer be conducted solely in writing; instead, you will be provided with a court date. Your Medicare contractor and/or CMS may be asked to participate.
- The controversy at the crux of the appeal must meet the minimum amount of $120.00 to reach this level of appeal.
- The ALJ is required to issue a written ruling with 90 days from the date that OMHA receives the hearing request.
- The ALJ decision is binding unless revised by the ALJ, Federal District Court and Medicare Appeals Council
Fourth Level Appeal: Medicare Appeals Council
- You can file a request for review within 60 days of the ALJ’s decision if you receive an unfavorable decision.
- The ALJ’s decision is reviewed by the Medicare Appeals Council. The Council has the right to modify, reverse, or remand the case back to the ALJ within 60 days of the filing.
Fifth Level Appeal: Federal District Court
- If all previous appeals fail, you can file a lawsuit within 60 days of receipt of the Medicare Appeals Council’s decision.
- There must be at least $1,260.00 at stake before this appeal can be filed.
This information is not intended to serve as a substitute for legal advice. You may want to consider consulting an attorney if you are the subject of a RAC audit. You can choose to do so at any point in the process, but you will need to do so if you file an appeal with an ALJ.
The ACC cannot provide legal advice. The College recommends that you consult an attorney who is well-versed in healthcare law. The American Health Lawyer Association may be able to assist you in locating a healthcare expert in your area.