Mid-Atlantic Health Law TOPICS
Medicare Appeals
In May, the Centers for Medicare and Medicaid Services (CMS) published a final rule (the Final Rule) that streamlines the Medicare Part A, Part B and Part D appeals processes for appealing a Medicare coverage determination.
When a contractor or plan issues a Part A or B initial determination or a Part D coverage determination, the contractor or plan notifies the provider, supplier and/or beneficiary and offers the opportunity to appeal the determination. If the determination is appealed, the contractor or plan reviews the determination, which is known as a redetermination.
If the redetermination is appealed, an independent contractor conducts an independent review of the administrative record, including the redetermination, which is known as a reconsideration.
If a minimum amount in controversy is met, a party can appeal a reconsideration determination to the Office of Medicare Hearings and Appeals, or to an attorney adjudicator, and then ultimately to the Medicare Appeals Council within the Departmental Appeals Board.
The varying levels of appeal requests use standard forms. For the first two levels of appeal requests, the form requires a signature; however, for the last two levels of appeal requests, the form does not require a signature. The Final Rule eliminates the signature requirements for the first two levels of appeal requests. Historically, Medicare administrative contractors and independent contractors dismiss more than 284,000 Medicare appeal requests annually for missing signatures.
Barry Rosen
410-576-4224 • brosen@gfrlaw.com