CMS Medicare Specialist Appeals & Grievances Process

Question 1

What is the difference between a Medicare grievance and an appeal?

Accepted Answer

A grievance is a complaint about care or service quality; an appeal contests a coverage or payment decision

Answer

A grievance contests a coverage denial; an appeal is a complaint about service quality

Answer

They are the same process with different names

Answer

A grievance applies only to Part A; an appeal applies only to Part D

Question 2

What is the first level of the Medicare fee-for-service appeals process?

Accepted Answer

Medicare Administrative Contractor Redetermination

Answer

ALJ Hearing

Answer

Qualified Independent Contractor Reconsideration

Answer

Judicial Review

Question 3

How many days does a beneficiary typically have to file a Medicare redetermination request with the MAC?

Accepted Answer

120 days

Answer

30 days

Answer

60 days

Answer

180 days

Question 4

At which appeal level does an independent reviewer outside Medicare review the case?

Accepted Answer

QIC Reconsideration

Answer

MAC Redetermination

Answer

ALJ Hearing

Answer

Judicial Review

Question 5

What minimum dollar threshold must be in dispute to request an ALJ hearing for a Medicare Part A or B appeal in 2024?

Accepted Answer

$220

Answer

$100

Answer

$180

Answer

$500

Question 6

Which office handles ALJ hearings for Medicare appeals?

Accepted Answer

Office of Medicare Hearings and Appeals (OMHA)

Answer

Centers for Medicare & Medicaid Services

Answer

Medicare Appeals Council

Answer

Social Security Administration