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

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?

Accepted Answer

120 days

Answer

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?

Accepted Answer

Reconsideration by a Qualified Independent Contractor (QIC)

Answer

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?

Accepted Answer

$180 (adjusted annually)

Answer

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?

Accepted Answer

The Medicare Advantage plan itself issues a redetermination

Answer

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.

(CMS) Certified Medicare Specialist Practice Test

(CMS) Certified Medicare Specialist Practice Test

CMS Medicare Specialist Appeals & Dispute Resolution