Virtually all adverse determinations made regarding Medicare claims can be appealed using Medicare's formal appeals process. There are five steps to the Medicare appeals process:

  • Redetermination by Medicare contractor
  • Reconsideration by Qualified Independent Contractor (QIC)
  • Hearings before an Administrative Law Judge (ALJ) within the Office of Medicare Appeals and Hearings in the Department of Health and Human Services (HHS)
  • Review by the Appeals Council within the Departmental Appeals Board in HHS
  • Judicial review in federal district court

For more information on Medicare appeals process, Medicare has created a concise overview. Close attention must be paid to all filing requirements and deadlines.

The ACC cannot provide legal advice to its members. An attorney may be retained at any point in the appeals process.

Private Payer Appeals

Each private payer has its own process for addressing claims disputes. The ACC recommends that physicians consult their contracts and individual payer’s website for more information on the dispute resolution process.