Provider agreements (or the ancillary documents) outline the formal processes to appeal payers’ payment decisions. You must review your agreement (or ancillary documents) with the specific payer to comply with the rules of the appeal process. A meritorious appeal may fail because you didn’t meet deadlines, follow the outlined procedures, or provide the necessary information.
For example, the payer may set a time limit for when a provider may appeal a payment decision. These time limits may range from 60-180 days, or more. Also, state law may set certain time limits for such appeals. You will need to reconcile the two sets of deadlines. Further, be sure to include all pertinent documentation that supports your position when submitting your appeal.
For Medicare, the appeal time frames are as follows:
First Level of Appeal: Redetermination
The appellant must file the request for redetermination within 120 days from the date of receipt of the initial audit determination; however, the appellant must file an appeal within 30 days of the demand letter to stop recoupment. No minimum dollar amount is required for a redetermination.
Second Level of Appeal: Reconsideration
If a provider is dissatisfied with the redetermination decision issued by the Medicare contractor, CMS hires Qualified Independent Contractors (QICs) to conduct reconsiderations. The provider must file a request for reconsideration by a QIC within 180 calendar days of receipt of the redetermination decision. To stop the recoupment process, the provider must file the request for reconsideration within 60 days of the redetermination decision date.
The QIC will issue its decision within 60 days of the request for reconsideration. If the QIC cannot finish its review in time, it will inform you of your right to advance to the next level of appeal.
Third Level of Appeal: Administrative Law Judge Hearing
A provider who remains dissatisfied after the QIC’s reconsideration decision can request an administrative law judge (ALJ) hearing if at least $140 remains in controversy. You must file the request within 60 days of receipt of the reconsideration decision. Generally, the ALJ will issue a decision within 90 days of his or her receipt of the hearing request.
Fourth Level of Appeal: Appeals Council Review
Any party to the ALJ hearing dissatisfied with the result may request that the Appeals Council review the case. There is no monetary minimum threshold for Appeals Council review. The appellant must request this review in writing within 60 days of receipt of the ALJ’s decision, and the request must identify the contested issues and findings. The Appeals Council will typically issue a decision within 90 days of its receipt of the request for review. If the Appeals Council fails to issue a decision within the allotted timeframe, the appellant may request that the Appeals Council escalate the case to the final level of appeal.
Fifth Level of Appeal: Judicial Review in U.S. District Court
If you are dissatisfied with the Appeals Council decision, you can appeal that decision to the United States District Court if at least $1,400 remains in controversy after the Council decision. The dissatisfied party has 60 days after the Appeals Council decision to request such review.