Parties to the Appeal

In general, there are two types of parties that are entitled to pursue a fee for service Medicare appeal at all stages of the appeal process, including the first level initial determination and redetermination stages, as well as the second level reconsideration stage that is handled by the Qualified Independent Contractor (QIC):

  • a Beneficiary who files a claim or has a claim filed on his or her behalf; and
  • a participating provider, physician or supplier who has filed a claim for items or services furnished to a beneficiary.

State Medicaid agencies and non-participating physicians and suppliers that have accepted an assignment of appeal rights from the beneficiary may also appeal, but their appeal rights do not begin until the redetermination stage of the Medicare appeal process.
It is important to note that prior to the new Medicare appeal process being implemented into law, providers had limited rights to appeal Medicare initial determinations. Providers could only appeal a claim determination when (1) the item/service was not covered because it constituted custodial care, was not reasonable and necessary, or for certain other reasons; and (2) the provider knew, or could reasonably have been expected to know, that the service in question was not covered under Medicare. Despite this restriction, providers routinely accessed the appeals process by acting as the beneficiary’s appointed representative in situations where they would otherwise not have had appeal rights. Current law now dictates that providers may file administrative appeals of initial determinations to the same extent as beneficiaries. Providers participating in the Medicare program no longer need an assignment of appeal rights from the beneficiary to pursue an appeal at the initial determination level.

 

For information about the availability of auxiliary aids and services, please visit:
http://www.medicare.gov/about-us/nondiscrimination/nondiscrimination-notice.html

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