NHIC California Appeals

A party dissatisfied with an initial Part B determination may appeal the decision in writing. There are several appeal levels and each level must be processed before proceeding to the next level.

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Appeals Process

After receiving the initial determination, there are five levels in the appeals process. Each level has procedural steps the appellant must take before appealing to the next level. If the appellant meets the procedural steps at a specific level, the appellant is then afforded the right to appeal any determination or decision to the next level in the process. The appellant may exercise the right to appeal any determination or decision to the next higher level, until appeal rights are exhausted.

Although there are five distinct levels in the Medicare Part B appeals process, the redetermination, the first level, is the only level performed by the Medicare Part B contractor. If an appellant is dissatisfied with this first level of appeal, a request must be sent to the Qualified Independent Contractor (QIC) by the appellant. If the appellant is dissatisfied with this second level, the appellant can request a hearing from the Administrative Law Judge (ALJ) hearing , level 3. To do so, a request must be made in writing to the Office of Medicare Hearings and Appeals (OMHA). If the decision is still dissatisfactory, the appellant may request a review within the Departmental Appeals Board. If an appellant has exhausted these first four levels, the appellant may appeal to the Federal courts, provided the appellant satisfies the requirements for obtaining judicial redetermination.

In the chart below is the administrative appeals process. Each level of appeal must be exhausted before moving to the next level.

CHART 1 - The Medicare Part B Fee-for-Service Appeals Process:

Appeal Level	Time Limit For Filing Request	Monetary Threshold To Be Met
1. Redetermination (Submit request to the Part B contractor)	120 days from date of receipt of the notice of the initial determination (allow an additional 5 days for mail delivery)	None
2. Reconsideration (Submit request to the QIC)	180 days from date of receipt of the redetermination (allow an additional 5 days for mail delivery)	None
3. Administrative Law Judge (ALJ) Hearing	60 days from the date of receipt of the reconsideration	At least $120 remains in controversy
4. Departmental Appeals Board (DAB) Review	60 days from the date of receipt of the ALJ hearing decision	None
5. Federal Court Review	60 days from date of receipt of DAB decision or declination of review by DAB	At least $1,180 remains in controversy

Forms

1st level of appeal - Redetermination Form: http://www.cms.hhs.gov/cmsforms/downloads/cms20027.pdf

2nd level of appeal - Reconsideration Form: http://www.cms.hhs.gov/cmsforms/downloads/cms20033.pdf

Mailing Addresses - California

Redetermination

Northern California:
Medicare Redeterminations/Appeals
P.O. Box 2800
Chico, CA 95927-2800

Southern California:
Medicare Redeterminations/Appeals
P.O. Box 272854
Chico, CA 95927-2854

Overpayment Redetermination (use this address if you are appealing an overpayment)

Overpayment Redeterminations
P.O. Box 2808
Chico, CA 95927-2808

Reconsideration

First Coast Service Options, Inc.
QIC Part B North Reconsiderations
P.O. Box 45208
Jacksonville, FL 32232-5208

Articles

NHIC, Corp.'s (NHIC) strategy has been developed to achieve the goal of the Centers for Medicare & Medicaid Services (CMS) program to assure that the Medicare program makes payments only for covered, correctly coded services and to reduce payment error rate. Moreover, our strategy is to use education, proactively and retroactively, as the primary corrective action whenever possible.

These articles are intended to assist providers with the above purposes in mind.

Appeals/Redetermination Articles

01/17/2008

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