CMS Medicare Specialist Appeals & Dispute Resolution 1 — Questions and Answers
Question 1: What is the first level of the Medicare claims appeal process for Part A and Part B claims?
- Redetermination by the Medicare Administrative Contractor (MAC) (Correct answer)
- Reconsideration by a Qualified Independent Contractor (QIC)
- Hearing before an Administrative Law Judge (ALJ)
- Review by the Medicare Appeals Council
Correct answer: Redetermination by the Medicare Administrative Contractor (MAC)
The first level of appeal is a redetermination, which is conducted by the same MAC that made the initial claims determination.
Question 2: How many days does a beneficiary or provider have to file a redetermination request after receiving an initial Medicare claims determination?
- 120 days (Correct answer)
- 60 days
- 30 days
- 90 days
Correct answer: 120 days
A party must file a redetermination request within 120 days of receiving the initial determination (assuming receipt within 5 days of the determination date).
Question 3: What is the second level of the Medicare Part A/B appeal process?
- Reconsideration by a Qualified Independent Contractor (QIC) (Correct answer)
- Hearing before an Administrative Law Judge (ALJ)
- Review by the Medicare Appeals Council (MAC Council)
- Federal district court review
Correct answer: Reconsideration by a Qualified Independent Contractor (QIC)
After an unfavorable redetermination, the next step is reconsideration by a QIC, which is an independent entity separate from the MAC.
Question 4: What minimum dollar amount in controversy is required to request an Administrative Law Judge (ALJ) hearing for a Medicare Part A or Part B appeal?
- $180 (adjusted annually) (Correct answer)
- $100
- $500
- $1,000
Correct answer: $180 (adjusted annually)
An ALJ hearing requires a minimum amount in controversy that is adjusted annually; for 2024 it was approximately $180, set by regulation.
Question 5: Which entity reviews Medicare Part C (Medicare Advantage) organization determinations at the first appeal level?
- The Medicare Advantage plan itself issues a redetermination (Correct answer)
- The MAC processes the first-level appeal for MA plans
- A QIC handles all MA plan appeals at level one
- CMS directly reviews MA plan denials
Correct answer: The Medicare Advantage plan itself issues a redetermination
For Medicare Advantage, the plan itself conducts the first-level appeal called a redetermination, similar to Part A/B but administered by the MA plan.
Question 6: What is the timeframe for a Medicare Advantage plan to complete a standard organization determination for a service authorization request?
- 14 calendar days (Correct answer)
- 7 calendar days
- 30 calendar days
- 72 hours
Correct answer: 14 calendar days
MA plans must complete standard organization determinations for services within 14 calendar days of the request.
CMS Medicare Specialist Appeals & Dispute Resolution 1
What is the first level of the Medicare claims appeal process for Part A and Part B claims?