• The original decision will be affirmed.
• The original decision will be reversed.
• The appeal will be dismissed.

This article discusses the third and most annoying outcome--a dismissal. When an appeal is dismissed, you do not have the option to request the next level of appeal.

First Level of Appeal, Redetermination

Appeals of initial determinations are commonly dismissed because they were not submitted within 120 days of the initial decision, because the service was paid on another claim, or because the requester withdrew the petition for a redetermination.

A request for the first level of appeal must be submitted within 120 days from the date the claim finished processing. Weekends and holidays count toward the 120 days. The starting date appears on your Medicare statement.

Following are the pieces of information that must accompany your request for appeal of an initial claim decision:

• Beneficiary’s name
• Beneficiary''s Health Insurance Claim Number (HIC)
• Date(s) of service in question
• Which service(s) are being appealed
• The name and signature of the requester

If you prefer, you may use the Medicare Part B Claim Inquiry/Appeal Request Form. To obtain a copy, please go here.

Documentation of what was done and why it was done is important to an appeal. The physician is responsible for providing the carrier with supporting documentation, that may include:

• X-ray reports, test results, medical history, consultation reports, billing forms, referrals, treatment plans, nursing notes, copies of pertinent communications with the provider and evidence of severity or acute onset of the condition.

• Providers or suppliers may appeal a claim decision by telephone, if the appeal is not complex. An appeal would be considered complex if substantial documentation is needed for its adjudication.

Second Level of Appeal

If you are not satisfied with the redetermination decision, your next level of appeal is the reconsideration (formerly a Fair Hearing). This process will be changing in January 2006, when the hearing will be held by a Qualified Independent Contractor (QIC) rather than by hearing officers at the Carrier.

For further information on the appeals process, go here.