CMS Medicare Specialist Appeals & Dispute Resolution

Question 1

What is the first level of the Medicare claims appeal process for Part A and Part B claims?

Accepted Answer

Redetermination by the Medicare Administrative Contractor (MAC)

Answer

Reconsideration by a Qualified Independent Contractor (QIC)

Answer

Hearing before an Administrative Law Judge (ALJ)

Answer

Review by the Medicare Appeals Council

Question 2

How many days does a beneficiary or provider have to file a redetermination request after receiving an initial Medicare claims determination?

Accepted Answer

120 days

Answer

60 days

Answer

30 days

Answer

90 days

Question 3

What is the second level of the Medicare Part A/B appeal process?

Accepted Answer

Reconsideration by a Qualified Independent Contractor (QIC)

Answer

Hearing before an Administrative Law Judge (ALJ)

Answer

Review by the Medicare Appeals Council (MAC Council)

Answer

Federal district court review

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?

Accepted Answer

$180 (adjusted annually)

Answer

$100

Answer

$500

Answer

$1,000

Question 5

Which entity reviews Medicare Part C (Medicare Advantage) organization determinations at the first appeal level?

Accepted Answer

The Medicare Advantage plan itself issues a redetermination

Answer

The MAC processes the first-level appeal for MA plans

Answer

A QIC handles all MA plan appeals at level one

Answer

CMS directly reviews MA plan denials

Question 6

What is the timeframe for a Medicare Advantage plan to complete a standard organization determination for a service authorization request?

Accepted Answer

14 calendar days

Answer

7 calendar days

Answer

30 calendar days

Answer

72 hours