Fee-for-Services Providers:

This web page provides an overview of the five levels of the Medicare Part A and B administrative appeals process available to providers, physicians and other suppliers who provide services and supplies to Medicare beneficiaries. Links are also provided to help you  obtain more information about this appeals process.

The Centers for Medicare & Medicaid Services (CMS) contracts with private insurance companies (called Carriers for Part B and Fiscal Intermediaries (FI) for Part A) to perform many processing functions on behalf of Medicare, including local claims processing and the adjudication functions.

NOTE:

Medicare Contracting Reform (MCR) Update - Section 911 of the Medicare Prescription Drug, Improvement, and Modernization Act of 2003 (MMA) enacted numerous contracting reforms. A key aspect of these reforms is that Medicare will begin integrating Fiscal Intermediaries (FIs) and Carriers into a new single authority, called a Medicare Administrative Contractor (MAC). As of October 1, 2005, new Medicare Contractors are called MACs. Also, from October 2004 through October 2011, all existing FI and Carrier contracts will be transitioned into MAC contracts, using competitive procedures. Providers may access the most current MCR information to determine the impact of these changes at Medicare Contracting Reform web page on the CMS website.

The Five Levels of the Appeal Process

Medicare offers five levels in the Part A and B appeals process. The levels, listed in order, are:

1. Redetermination
2. Reconsideration
3. Administrative Law Judge (ALJ) Hearing
4. Departmental Appeal Board Review
5. Judicial Review in US District Court
   

Qualified Independent Contractors (QICs)

The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act of 2000 (BIPA) included provisions aimed at improving the Medicare appeals process.  Part of these provisions mandate that all second-level appeals, also known as reconsiderations, be conducted by Qualified Independent Contractors (QICs).  These provisions require that QICs utilize a comprehensive data system to collect and share information about appeals decisions, give weight to carrier and fiscal intermedicary local coverage determinations, and conduct a panel review of all medical necessity denials.

CMS awarded contracts to eight Qualified Independent Contractors (QICs) to perform reconsiderations of denied Medicare fee-for-service claims.

The reconsiderations that will be conducted by the QICs will replace the Hearing Officer Hearing process for Medicare Part B claims and establish a new second level of appeal for Medicare Part A claims.   

The eight entities selected were:

• Q² Administrators (Q²A);

• IntegriGuard;

• Island Peer Review Organization (IPRO);

• Rivertrust Solutions, Inc.;

• Computer Sciences Corporation (CSC);

• Maximus, LLC;

• First Coast Service Options, Inc.; and,

• Permedion.

Downloads
New Expedited Review Process for Disputed Terminations of Medicare-Covered Services in SNFs, HHAs, CORFs, and Hospices Special Edition MLN Matters Article SE0538 [PDF 272KB] Revisions to Medicare Appeals Process for Fiscal Intermediaries (CR Title-Appeals Transition - BIPA 521 Appeals) MM3530 [PDF 345KB] Comparison of Current and BIPA 521 Fee-For-Service Appeal Processes [PDF 16KB] Implementing A New Medicare Claims Appeals Process [PDF 76KB] Medicare Appeals Process brochure [PDF, 127KB] DME QIC Jurisdiction [PDF, 24KB] Part B QICs Jurisdictions [PDF, 56KB] Qualified Independent Contractors (QIC) Fact Sheet [PDF, 25KB]
Related Links Inside CMS
Medicare Contracting Reform Appeals - Managed Care MLN General Information MLN Matters Articles MLN Products MLN Product Ordering Page Web Based Training (WBT) Modules CMS Forms Beneficiary Notices Initiative (BNI) Quality Improvement Organizations (QIO)
Related Links Outside CMS
Social Security Act — The Medicare Program [PDF 1.1 MB] Medicare Modernization Act of 2003 - See Title X, Subtitle D section 931-940A "Appeals and Recovery"[PDF 15MB] Federal Register Notices [PDF, 5KB] Qualified Independent Contractors (QIC) [PDF, 3KB] Office of Medicare Hearings and Appeals (OMHA) Departmental Appeals Board (DAB)

Page Last Modified: 11/07/2006 12:00:00 AM
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