CMS Pub. 100-04, ch. 29, § 220

Regulations at 42 CFR 405.940-405.942 provide that a party to a redetermination that is dissatisfied with an

initial determination may request that the contractor make a redetermination. The request for redetermination

must be filed within 120 days after the date of receipt of the notice of the initial determination (the notice of

initial determination is presumed to be received 5 days after the date of the notice unless there is evidence to

the contrary). Contractors cannot accept an appeal for which no initial determination has been made. The

parties specified in §210 who are dissatisfied with a determination on their Part A or B claim have appeal

rights.

The appeals process consists of five levels. The appellant must begin the appeal at the first level after

receiving an initial determination. Each level, after the initial determination, has procedural steps the

appellant must take before appealing to the next level. Each level is discussed in detail in subsequent

sections. If the appellant meets the procedural steps at a specific level (including the amount in controversy

(AIC) requirement if applicable), the appellant (and all other parties to the appeal decision) is then afforded

the right to appeal any determination or decision to the next level in the process. The appellant may exercise

the right to appeal any determination or decision to the next higher level, until appeal rights are exhausted.

Although there are five distinct levels in the Medicare appeals process, the redetermination, level 1, is the

only level in the appeals process that the contractor performs.

When an appellant requests a reconsideration with a QIC (level 2), the contractor must prepare and forward

the case file to the QIC. Further, the contractor may have effectuation responsibilities for decisions made by

the QIC. The contractor, however, does not have responsibility for reviewing the QIC’s decision for

accuracy. When an appellant requests an Administrative Law Judge (ALJ) hearing or review by an attorney

adjudicator (level 3), the QIC must prepare and forward the case file to the OMHA. Further, the contractor

may have effectuation responsibilities for decisions made at OMHA, Departmental Appeals Board

(DAB)/Appeals Council, and Federal Court levels.

In the chart below, levels 1 – 4 are part of the Administrative Appeals Process. If an appellant has completed

all the first 4 steps of the administrative appeals process and is still dissatisfied, the appellant may appeal to

the Federal courts, provided the appellant satisfies the requirements for obtaining judicial review.

CHART 1 - The Medicare Fee-for-Service Appeals Process

APPEAL LEVEL TIME LIMIT FOR FILING

REQUEST

MONETARY

THRESHOLD TO BE MET

1. Redetermination 120 days from date of receipt

of the notice initial

determination

None

2. Reconsideration 180 days from date of receipt

of the redetermination*

None

3. Administrative Law

Judge (ALJ) Hearing

60 days from the date of

receipt of the reconsideration

Current AIC requirements can be

found on CMS.gov at:

http://www.cms.gov/Medicare/Ap

peals-and-

Grievances/OrgMedFFSAppeals/

HearingsALJ.html.

See §250 for additional

information.

4. Departmental

Appeals Board (DAB)

Review/Appeals

Council

60 days from the date of

receipt of the ALJ hearing

decision

None

5. Federal Court

Review

60 days from date of receipt

of the Appeals Council

decision

Current AIC requirement can be

found on CMS.gov at:

http://www.cms.gov/Medicare/Ap

peals-and-

Grievances/OrgMedFFSAppeals/

Review-Federal-District-Court.html. See §345 for

additional information

*NOTE: If a party requests QIC review of a contractor’s dismissal of a request for redetermination, the time

limit for filing a request for reconsideration is 60 days from the date of receipt of the contractor’s dismissal

notice.