Medicare Appeals Process Update

Medicare Appeals Process Update

Starting September 1, 2025, Maximus will no longer send requests for additional documentation from DME suppliers that would support a favorable reconsideration, as instructed by CMS.

What You Need to Know

Maximus is the Qualified Independent Contractor for DME Medicare reconsiderations, the second level of the Medicare fee-for-service appeals process. In 2016, CMS launched the QIC Telephone Discussion and Reopening Process Demonstration, which allowed select suppliers and providers to participate in a telephone discussion at the second level of appeal. After the six-year Demonstration ended on December 31, 2021, the QICs were encouraged to identify opportunities and advise suppliers to submit required information to support a favorable decision. In these situations, Maximus sends the provider a letter requesting the necessary information and provides up to 14 calendar days for the requested documentation to be submitted. Earlier this year, CMS notified Maximus that they must stop these efforts starting September 1, 2025.

Note: This change does not apply to information requests associated with missing documentation necessary to validate an appeal (i.e., appointment of representation forms, evidence of a supplier/billing agency relationship, etc.).

 What This Means for You

If Maximus determines that information is missing from your reconsideration request, they will no longer be able to send you a follow-up letter requesting documentation that would support a favorable appeal decision. Therefore, to help prevent dismissals and denials, you should include the following information and documentation in your initial request:

• Beneficiary Name
• Beneficiary Medicare Number
• Specific item(s) for which the reconsideration is requested
• Specific date(s) of service
• Name of the party or representative of the party appealing
• Name of the MAC that made the redetermination
• Medicare's Redetermination Notice/Remittance Advice
• Your appeal letter
• Physician's order
• All pertinent medical records

If you submit the request using the QIC Appeals Portal, fill out all requested information and upload all relevant documentation with your submission. For requests that are faxed or mailed to Maximus, send the documentation listed above along with a completed Medicare Reconsideration Request Form. You can also upload or send additional documentation after Maximus receives your appeal request, but this should be done as soon as possible to prevent delays, dismissals, and denials.

Visit the Maximus website for more information on Filing a Medicare DME Appeal.