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Linda Collins Blogger

Medicare Appeals Process – Level 3: Administrative Law Judge

Posted by Linda Collins | April 25, 2016

The Medicare level 2 appeal is a reconsideration and is managed by a Qualified Independent Contractor (QIC.) If you are dissatisfied with the results of a Medicare level two appeal, you request the next level of appeal. The third level of appeal is managed by an Administrative Law Judge (ALJ.)

In order to qualify for an ALJ hearing, the amount of the denied claim must be at least $130.00. A request for an ALJ hearing must be submitted within 60 days of the reconsideration decision. The standard form CMS-20034 A/B may be used to file a request for an ALJ hearing.

ALJ hearings are generally held by telephone. You may ask for an in-person hearing if you can identify cause for requesting an in-person hearing. The ALJ will determine whether an in-person hearing is warranted on a case-by-case basis. The ALJ will generally issue a decision within 90 days of receipt of the hearing request.

If after the ALJ hearing, you are dissatisfied with the decision and believe you have a strong appeal, you may request a review by the Medicare Appeals Council. There are no requirements regarding the amount of money in controversy. The request for Medicare Appeals Council review must be submitted in writing within 60 days of receipt of the ALJ's decision, and must specify the issues and findings that are being contested. The decision notice from the ALJ decision will provide details regarding the procedures to follow when filing a request for Medicare Appeals Council review.

The fifth and final level of appeal is a Judicial Review in the Federal District Court. In order to qualify for this level of appeal, there must be at least $1,500 in dispute. You must request a Judicial Review within 60 days or receipt of the Medicare Appeals Council decision. The Medicare Appeals Council's decision will contain information about the procedures for requesting judicial review.

Additional information about the Medicare appeals process can be found in the CMS brochure, Medicare Parts A&B Appeals Process and Medicare Appeals Flowchart

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