Overview
There are five levels of appeals for Medicare revocation cases. Below is a breakdown of each level, including timelines and decision processes.
1st Level – Determination
Medicare Administrative Contractor (MAC) Review
Process: MAC reviews the documents related to the initial claim determination.
Timeline:
You have 120 days after receiving the initial determination to appeal.
The action decision takes approximately 60 days.
2nd Level – Redetermination
Qualified Independent Contractor (QIC) Review
Process:
QIC conducts a document review of the redetermination.
You should submit any evidence not previously presented at this level.
Timeline:
Request the appeal within 180 days after receiving the MRN/RA.
Expect an action decision within 60 days.
3rd Level – ALJ Hearing
Administrative Law Judge (ALJ) Review
Process:
May be an on-the-record review or an interactive hearing between parties.
Timeline:
Request an appeal within 60 days after receiving the QIC decision or after the expiration of the applicable QIC reconsideration timeframe if no decision is received.
The timeline for the action decision depends on case volume.
4th Level – Medicare Appeals Council Review
Appeals Council Review
Process:
Document review of the ALJ’s decision or dismissal.
You may also request oral arguments.
Timeline:
Appeal within 60 days after receiving the ALJ’s decision or after the expiration of the ALJ hearing timeframe if no decision is received.
Expected decision timeframe:
90 days if appealing an ALJ decision
180 days if the ALJ review timeframe expired without a decision
5th Level – U.S. District Court Review
Judicial Review
Process:
The U.S. District Court reviews the Appeals Council’s decision.
Timeline:
Appeal within 60 days after receiving the Appeals Council decision or after the expiration of the Appeals Council review timeframe if no decision is received.
No statutory time limit for the court’s decision.
Frequently Asked Questions
What is the first step in the Medicare revocation appeals process?
The first level is the Determination, where a Medicare Administrative Contractor (MAC) reviews the documents related to the initial claim. You must file an appeal within 120 days of the initial decision, and a response typically takes around 60 days.
Can I present new evidence during the redetermination phase?
Yes, during the Redetermination (2nd level) handled by a Qualified Independent Contractor (QIC), you should submit any supporting evidence not previously presented. The appeal must be filed within 180 days, and a decision is expected within 60 days.
How is the Administrative Law Judge (ALJ) hearing different from prior levels?
The ALJ hearing (3rd level) may involve an interactive session or an on-the-record review, unlike the purely document-based earlier stages. You have 60 days to request this hearing after the QIC decision, and the decision timeline varies depending on case backlog.
What happens if the ALJ doesn’t issue a decision?
If the ALJ fails to provide a decision, you may still proceed to the Medicare Appeals Council Review (4th level). The decision timeline in this level is 90 days for ALJ-issued decisions or 180 days if no decision was issued within the expected timeframe.
Is there a deadline for the U.S. District Court to decide the appeal?
No, while you must appeal to the U.S. District Court (5th level) within 60 days of the Appeals Council’s decision or deadline expiry, there is no statutory time limit for when the court must issue its decision.
