First Level of Appeal, Redetermination
If you are dissatisfied with the denial of a claim or believe that it was not properly paid, you may request a redetermination. All requests for redetermination must be requested within 120 days of the original claim determination.

Written requests for redetermination may be made on the form included at the end of this article, as a written statement, or on the CMS-1964 form. All requests must contain the following information. Requests will be returned if missing one or more of the following:

• Beneficiary name;
• Medicare health insurance claim (HIC) number;
• Name and address of the physician/supplier of item/service;

NOTE: Please indicate the group number if the claim was processed under the group.

• Date of initial determination (claim number is acceptable);
• Date(s) of service;
• Which item(s) and/or service(s) are at issue; and
• Signature of the appellant.

NOTE: The signature must be on the request for redetermination. Signatures contained on medical records are not acceptable as a valid signature for review requests.

Requests for redetermination of nonassigned claims must include a completed Appointment of Representative form (CMS-1696 U4) or a written statement. Please see the Appointment of Representative section of this article for further information.

You are responsible for sending the carrier documentation in support of the case. Documentation may include:

• Billing forms
• Clinical summaries
• Consultation reports
• Copies of communications between physician and/or patient, hospital, carrier, laboratory, etc.
• Documentation of severity or acute onset
• Medical history
• Nurse’s notes
• Plan of treatment
• Referrals
• Test results
• X-ray reports

Second Level of Appeal, Hearing Officer Hearing
If you are still dissatisfied with the redetermination and the amount in controversy is at least $100, you may request a hearing. A combination of claims involving different services can be submitted in order to meet the $100 minimum. When requesting a hearing, the following requirements must be met:

• If applicable, requests must specifically state that claims are being aggregated;
• The claims must have gone through the redetermination process;
• Requests must be made within six months of the redetermination notice;
• Requests must be signed by the appellant; and
• The hearing request must identify each claim.

A hearing is conducted by a hearing officer who has the knowledge of medical matters and terminology. This officer also has a thorough understanding of the Medicare program and the statutory authority and regulation upon which it is based, as well as rulings, policy statements, and general instructions issued by Medicare. Most importantly, the hearing officer cannot have been involved in the initial appeal redetermination.

You will be given the opportunity to have a hearing conducted without actually making an appearance if you prefer.

Types of Hearings:

In-Person
The physician or representative of the physician is afforded the opportunity to present both oral testimony and written evidence supporting the claim, and to refute or challenge the information used to deny the claim or prior payment determination.

Telephone
The physician or representative may present oral testimony to the hearing officer and is given the opportunity for oral challenge of the carrier’s determination. This type of hearing eliminates the need for you or your representative to appear.

On-the-record
The decision is made by the hearing officer based on the facts that are in the file, including any additional information provided to the hearing officer by the physician or representative. The major advantage is the speed in which the decision is rendered.

You will receive written confirmation in the mail when the date has been scheduled for an in-person and/or telephone hearing. At the hearing, you will have the right to present oral arguments, be represented by council, bring witnesses, and present briefs or affidavits in lieu of testimony.

The hearing officer will issue a decision no later than 30 days after the in-person or telephone hearing and will include:

• A statement of the service(s) and issue(s);
• A summary of the pertinent facts;
• The decision;
• A brief explanation of its basis;
• Proper reference to law, regulations, and policy;
• A statement that copies of the applicable law, regulations, and policy upon which the decision is based are available upon request; and
• A statement providing any further appeal rights.

Administrative Law Judge
If you are dissatisfied after the Medicare hearing decision, and the amount in controversy is at least $100, you may file a request to present your case to an Administrative Law Judge (ALJ) of the Social Security Administration. This must be done within 60 days of the date of the Medicare hearing decision. If less than $100 remains, you may combine claims to meet the $100 minimum.

The provider must include the following when requesting an ALJ hearing:

• Witness’s name (if applicable);
• Reasons for disagreement with the hearing officer’s decision;
• Date of the carrier denial;
• Surgery or treatment reports; and
• Any medical documentation that supports the case.

You will be notified 20 days prior to the hearing. The judge will review the case in light of Medicare laws and regulations. Within 30 to 60 days following, you will receive a written ruling from the judge describing the factual findings and reasoning for the decision based on the evidence from the hearing included in the record. The judge’s decision is binding.

Finally, if you have exhausted all of the appeal steps noted above, you may appeal to federal court if the amount in controversy is at least $1,000.

Additional Information Regarding the Appeals Process

Parties to an Appeal
Any of the following persons or entities are considered a party to an appeal of a claim for items or services payable under Part B and, therefore, may appeal the initial claim determination and any subsequent appeal decisions:

• A beneficiary;
• A participating physician or supplier (one who has agreed to accept assignment on all claims);
• A nonparticipating physician or supplier who has accepted assignment for a specific service/claim;
• A nonparticipating physician not accepting assignment, but responsible for refunding the beneficiary under section 1842(1)(1) of the Social Security Act.
• A nonparticipating supplier of durable medical equipment responsible for refunding the beneficiary under section 1834(a)(18) of the Social Security Act.
• A supplier of medical equipment and supplies furnishing items to a beneficiary on a nonassigned basis and responsible for refunding the beneficiary under section 1834(j)(4) of the Social Security Act;
• A Medicaid State agency, or party authorized to act on behalf of the State; and
• Any individual whose rights with respect to the particular claim being reviewed may be affected by such review and any other individual whose rights with respect to supplementary medical insurance benefits may be prejudiced by the decision.

Requests for an appeal submitted by someone other than those listed will be dismissed.

Appointment of Representative
A party may appoint any individual, including an attorney, to act as his/her representative. Although some parties may pursue a claim or an appeal on his/her own, others will rely upon the assistance and expertise of others. A representative may be appointed at any point in the appeals process. A representative may help the party during both the processing and appeal of a claim or claims. The appointment of a representative is valid for 1 year from either 1) the date signed by the party making the appointment, or 2) the date the appointment is accepted by the representative, whichever is later.

Who May Be a Representative—Any individual may be appointed to act as a representative unless he/she is disqualified or suspended from acting as a representative in proceedings before CMS or is otherwise prohibited by law.

A specific individual must be named as the representative. An organization or entity may not be named as a representative, but rather a specific member of that organization or entity must be named. This ensures that confidential beneficiary information is only released to the individual so named.

A physician or other supplier who files an appeal request on behalf of a beneficiary is not, by virtue of filing the appeal, a representative of the beneficiary. To act as the beneficiary’s representative, the physician or other supplier must meet the criteria set forth in this section.

A representative should keep a completed appointment on file and submit a copy with each claim appealed.

NOTE: Billing clerks or billing services employed by the physician or supplier to prepare and/or bill the initial claim, process the payments, and/or pursue appeals act as the agent of the physician or other supplier and do not need to be appointed as representative of the physician/supplier.

How to Make and Revoke an Appointment—The party making the appointment and the individual accepting the appointment must either complete an appointment of representative form (Form CMS-1696-U4) or submit a written statement. A party may appoint a representative at any time during the course of an appeal. The representative must sign the appointment form or written statement within 30 calendar days of the date the beneficiary or other party signs in order for the appointment to be valid. By signing the appointment, the representative indicates his/her acceptance of being appointed as representative.

Attorney Representatives—If the person representing the party is an attorney, the attorney is not required to sign the representative form or a written statement. However, if it is not evident that the individual representing the party is an attorney, a business card, letterhead, or written statement is required.

Required Elements—The following information must be included on an appointment of representative form or written statement:

• Name/Address/Phone Number of party (i.e., the beneficiary or physician or other supplier).
• Health Insurance Claim Number, when the party making the appointment is a beneficiary.
• Medicare Physician/Supplier Number, when the party making the appointment is a physician or other supplier.
• Name/Address/Phone Number of the individual being appointed as representative.
• A statement that the party (i.e., the beneficiary or the physician or other supplier) is authorizing the representative to act on her/his behalf for the claims at issue and a statement authorizing disclosure of individually identifying information to the representative (in cases where the representative is not the provider of services).
• Signature of the party making the appointment and the date signed.
• Signature of the individual being appointed as representative, accompanied by a statement that he/she accepts the appointment, and the date signed; however, if the individual being appointed as representative is an attorney, the attorney does not need to accept the appointment in writing.
• Prohibition Against Charging a Fee for Representation:

A physician or other supplier that furnished items or services to a beneficiary may represent that beneficiary on his/her claim or appeal involving those items or services. However, the physician or other supplier may not charge the beneficiary a fee for representation in this situation. Further, the physician or other supplier being appointed as representative must acknowledge that he/she will not charge the beneficiary a fee for such representation. The physician or other supplier does this by including a statement to this effect on the form or written statement, and then signs and dates it.

• Waiver of Right to Payment from the Beneficiary for the Items or Services at Issue:

For beneficiary appeals involving the denial of the claim on the basis of section 1862(a)(1) or (a)(9), or section 1879(g) of the Act, and where a limitation on liability determination made under section 1879 of the Act determined that both the beneficiary and the physician or other supplier, knew or could reasonably have been expected to know, that the item or service would not be covered, and where the physician or other supplier that furnished the items or services at issue is also serving as the beneficiary’s representative, the physician or other supplier must waive, in writing, any right to payment from the beneficiary for the items or services at issue (including coinsurance and deductibles). The physician or other supplier representative does this by including a statement to this effect on the form or written statement, and then signs and dates it.

The prohibition against charging a fee for representation, and the waiver of right to payment from the beneficiary for the items or services at issue, do not apply in those situations in which the physician or other supplier merely submits the appeal request on behalf of the beneficiary or at the beneficiary’s request (i.e., where the physician or other supplier is not also acting as representative for the beneficiary), or where the items or services at issue were not provided by the physician or supplier representative.

When to Submit the Appointment—A representative, beneficiary, or other party may submit the completed appointment at the time such person files a request for appeal or at any time during the processing of the appeal.

Note that a completed appointment of representative form or written statement, or a copy of such form or statement, must be submitted with each appeal request.

Validity of an Appointment Over Time—A new appointment of representative form or written statement does not need to be executed each time an appeal is filed by the same representative who is representing the same party. For the administrative convenience of both the party making the appointment and the representative, the representative may maintain a completed appointment on file and then submit a copy with each new appeal request.

Aggregation of Claims—Hearing Level
The law requires that at least $100 remain in controversy for you to request a Hearing Officer hearing, that your request for Hearing Officer hearing be filed within six (6) months of the date on the redetermination, AND, that your request must be made in writing.

If less than $100 remains in controversy, you may combine the claim or claims that are the subject of a redetermination with claims from other recently issued redetermination you have received (or may receive) to meet the $100 amount remaining in controversy requirement. This is called "Aggregating Claims."

To "aggregate claims," EACH CLAIM included in your request for a Hearing Officer hearing must be appealed within six (6) months from the date the redetermination was issued on the claim and each claim must have already received a redetermination.

If you wish to request a Hearing Officer hearing by combining the amounts remaining in controversy from other claims, you MUST clearly state on your request for a hearing that you are "aggregating claims," AND you must list the specific claims that you are aggregating. The decision about whether or not the aggregation requirements have been met is made by the Hearing Officer. If you do not clearly state on your request for a hearing that you are aggregating claims, the Hearing Officer will have to treat each claim as an individual request for hearing, and will have to dismiss those claims that do not meet the amount in controversy.

A party may aggregate claims to meet the $100 amount remaining in controversy requirement for a hearing in one of two ways:

1. An individual beneficiary may combine claims from two or more physicians or suppliers to meet the amount remaining in controversy requirement if each claim has had a review determination issued AND the request for Hearing Officer hearing is timely-filed for all of the claims included in the aggregation request; or,
2. An individual physician or supplier may combine claims from two or more beneficiaries to meet the amount remaining in controversy requirement if each claim has had a review determination issued AND the request for a Hearing Officer hearing is timely-filed for all of the claims included in the aggregation request.

Aggregation of Claims - Administrative Law Judge
To "aggregate claims" each claim included in your request for ALJ hearing must be appealed within 60 days from the date the Hearing Officer decision was issued on the claim, and each claim must have already received a Hearing Officer hearing decision.

If you want to request an ALJ hearing by combining the amounts remaining in controversy from other claims, you must state on your request for an ALJ hearing that you are "aggregating claims," and you must list the claims on your request.

A party may aggregate claims to meet the $100 amount remaining in controversy requirement for an Administrative Law Judge hearing in one or more of the following ways:

1. An individual beneficiary may combine claims from two or more physicians or suppliers to meet the amount remaining in controversy requirement IF each claim has had an Hearing Officer hearing decision issued AND the request for Administrative Law Judge hearing is timely-filed for all of the claims included in the aggregation request;
2. An individual physician or supplier may combine claims from two or more beneficiaries to meet the amount remaining in controversy requirement IF each claim has had an Hearing Officer hearing decision issued AND the request for Administrative Law Judge hearing is timely-filed for all of the claims included in the aggregation request;
3. Two or more beneficiaries may combine their claims for services received from either the same or different physician or supplier IF the claims involve common issues of law and fact, AND, each of the claims has had a Hearing Officer hearing decision issued, AND, the request for Administrative Law Judge hearing is timely-filed for all of the claims included in the aggregation request;
4. Two or more physicians or suppliers may combine their claims IF the claims involve the delivery of similar or related services to the same beneficiary, AND, each of the claims has had a Hearing Officer hearing decision issued, AND, the request for Administrative Law Judge hearing is timely-filed for all of the claims included in the aggregation request; or,
5. Two or more physicians or suppliers may combine their claims IF the claims involve common issues of law and fact for services furnished to two or more beneficiaries, AND, each of the claims has had a Hearing Officer hearing decision issued, AND, the request for an Administrative Law Judge hearing is timely-filed for all of the claims included in the aggregation request.

The Administrative Law Judge is responsible for deciding what are "common issues of law and fact" and what are "similar or related services." You may wish to include in your request for Administrative Law Judge hearing an explanation of why you think the claims that you have combined seem to involve either "common issues of law and fact" or why the claims are for "similar or related services."