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| Medicare Appeals -
Providers |
1.
What is an Appeal?
2.
What are our Appeal Rights?
3.
How do we Appeal a Claim?
4.
How does the Appeal Process work?
5.
What if we don’t agree with the Reconsideration
on my Part A Claim?
6.
What if we don’t agree with the Review
on my Part B Claim?
7.
What if we disagree with the Hearing Officer’s
decision?
Introduction
An appeal is a request to review a decision made on the
Medicare Part A Hospital (inpatient) and Part B Medical
(outpatient) services. When you disagree with the decision
on the RA send a letter to the Medicare Part A fiscal
intermediary stating clearly your complaint. For Medicare
Part A decisions, you must send your request for an appeal
within 60 days of receiving the notice if the notice
is dated September 30, 2002, or earlier
or
within 120 days of the date of this notice, if this notice
is dated October 1, 2002 or later. Within ten days from
receipt of the Part A request an acknowledgement letter
is sent to the requestor. For Part B decisions, you must
send the request for appeal within six (6) months of
receiving the notice if the notice is dated September
30, 2002, or earlier or within 120 days of the date of
this notice, if this notice is dated October 1, 2002
or later. At this time no acknowledgement letter is sent
to the beneficiaries.
1.
Appeal Rights
An appeal is a request to review a decision made on the
Medicare Part A Hospital (inpatient) and Part B Medical
(outpatient) services. When you disagree with the decision
on the RA send a letter to the Medicare Part A fiscal
intermediary stating clearly your complaint. For Medicare
Part A decisions, you must send your request for an appeal
within 60 days of receiving the notice if the notice
is dated September 30, 2002, or earlier
or
within 120 days of the date of this notice, if this notice
is dated October 1, 2002 or later. Within ten days from
receipt of the Part A request an acknowledgement letter
is sent to the requestor. For Part B decisions, you must
send the request for appeal within six (6) months. days
of receiving the notice if the notice is dated September
30, 2002, or earlier or within 120 days of the date of
this notice, if this notice is dated October 1, 2002
or later. At this time no acknowledgement letter is sent
to the beneficiaries.
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2.
Appeal Rights for the Provider
The provider’s right to appeal certain determinations
is limited. The provider may appeal an initial determination
when:
- Items or services are not covered because they
are not reasonable and necessary or constitute custodial
care
- The beneficiary has been found not liable for
the cost of the service(s) under the limitation of
liability, or the beneficiary will not request an
appeal.
Good cause for late filing must be established when the
written complaint arrives past the time frame for requesting
an appeal. When good cause is not found the request is
dismissed. You will be notified when a request is dismissed.
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3. How to Appeal a Claim
The Provider letter must express disagreement with a
specified initial determination and must include the
signature of the requestor. A request for Medicare Part
A reconsideration may be filed on Form HCFA-2649. This
form must include a signature and written specific expression
of disagreement. The form is located at:
A request for Medicare Part B review may be filed on
Form HCFA-1964. This form must include a signature and
written specific expression of disagreement. The form
is located at:
The Provider must include complete documentation with
the written appeal request. The following pertinent information
should be included in the request:
- Provider name, mailing address, and provider number
- Address were the services were performed
- Beneficiary name and Health Insurance Claim number
- Date of service on the claim reported to Medicare
- Identify the line item(s) or service(s) for review
- Brief explanation including the reason for the
request
To ensure prompt delivery to the Medicare Intermediary
office please send to: BLUE CROSS BLUE SHIELD OF ARIZONA
MEDICARE HEARINGS AND APPEALS DEPARTMENT
P O BOX 37700
PHOENIX AZ 85069-7700
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Appeal Process
4. First Appeal Level
An independent and thorough evaluation of the evidence
and prior findings is made. All the facts are reviewed
based on Medicare guidelines. The reviewer is looking
for the evidence submitted that is clear and convincing
and supported by documentation. The decision letter for
Medicare Part A (inpatient) is completed and mailed within
60 days from the date the reconsideration request was
received by the Intermediary. The decision letter for
Part B (outpatient) is completed and mailed within 45
days from the receipt of the review request.
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5. Second Appeal Level for Medicare Part A
If the beneficiary, beneficiary representative or the
provider is dissatisfied with the Medicare Part A (inpatient)
reconsideration determination letter you can go to the
next level of appeal. The second level of appeal for
Medicare Part A is called an Administration Law Judge
hearing. The following conditions must be met to go to
the second level:
- Prior review performed
- Amount in controversy after the determination
is more than $100
- Filed timely (written request postmarked within
60 days from the decision date)
- The requestor is a party to the hearing
The letter must specifically state your complaint with
the Medicare Part A determination letter. Send the request
letter and supporting documentation to the Intermediary
that forwarded your determination. Within ten days from
receipt of the Part A hearing request an acknowledgement
letter is sent to the requestor. The Administrative Law
Judge will notify you of the final decision.
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6. Second Appeal Level for Medicare Part B
If the beneficiary, beneficiary representative, or the
provider is dissatisfied with the Medicare Part B (outpatient)
review determination you can go to the next level of
appeal. The second level of appeal is a Part B Hearing.
The hearing request letter must specifically state your
complaint with the determination letter. Send the request
letter and supporting documentation to the Intermediary
that forwarded your determination. Within ten days from
receipt of the Part B hearing request an acknowledgement
letter is sent to the requestor. The following conditions
must be met to go to the next level:
- Prior review performed
- Amount in controversy after the determination
is more than $100
- Filed timely (written request postmarked within
6 months from the decision date)
- The requestor is a party to the hearing
A request for Medicare Part B Hearing may be filed on
Form HCFA-1965. This form must include a signature and
written specific expression of disagreement. The form
is located at:
You must choose the type of hearing that will be conducted.
When the choice is not specified an on-the-record hearing
is conducted. One of three types of hearings can be requested:
- On-the-Record hearing. A decision is made using
the facts contained in the hearing file. This includes
all information gathered before the hearing.
- Telephone hearing. Oral testimony is presented
over the telephone to support the case. The testimony
is taped in accordance to the Medicare guidelines
and admissible as evidence.
- In person hearing. The hearing is the same as
telephone just without your appearance.
The provider is responsible for ensuring that the necessary
documentation is submitted for review. The Hearing Officer
will secure the necessary documentation if applicable.
The Hearing Officer will schedule the hearing of your
choice. The Hearing Officer considers all relevant and
material facts. The written decision contains a statement
of the issues, evidence, rationale, specific findings
of fact and a conclusion. The Hearing Officer is bound
by applicable statute, regulations, and guidelines. A
decision will be rendered more than 120 days after the
request for hearing was received. The decision letter
is sent to the beneficiary, beneficiary representative,
and the provider.
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7. Third Appeal Level for Medicare Part B - ALJ Hearing
If the beneficiary, beneficiary representative, or the
provider is dissatisfied with the Hearing Officer’s
decision you can go to the next level of appeal. The
third level of appeal is an Administrative Law Judge
Hearing. A specific written request for a Part B ALJ
must be filed with the Intermediary. Within ten days
an acknowledgement letter will be sent to you explaining
the administrative law judge process. The following conditions
must be met to go to the next level:
- Prior Part B Hearing performed
- Amount in controversy after the determination
is more than $100
- Filed timely (written request postmarked within
6 months from the decision date)
- The requestor is a part to the hearing or is the
appointed representative.
Mail your request for the Medicare Part B ALJ to:
BLUE
CROSS BLUE SHIELD OF ARIZONA
MEDICARE HEARINGS AND APPEALS DEPARTMENT
P O BOX 37700
PHOENIX AZ 85069-7700
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