Chapter 18
Appeals and Hearings

18.1 Overview

In this section, we will describe the steps in an appeal process. The steps include:

Under Medicare part B, when a provider or beneficiary is dissatisfied with a determination concerning the amount paid on a claim or whether services received are covered by Medicare, they have the right to appeal the decision.

18.2 Appeals

A review is an independent re-examination of a claim. It is the first level of appeal. You may request a review if you are dissatisfied with the amount Medicare paid on your claim, or if your claim was denied because Medicare determined the services were not allowable due to coverage guidelines.

18.3 Filing a Request for a Review

Your request for review may be submitted in one of four ways: in writing, via fax, via telephone,and must be received within six months from the date the claim completed processing. Refer to the "date paid" on your reconciliation or summary voucher (EOMB) to determine the date the claim processed.

It is beneficial, although not always necessary depending on the problem, to provide us with a copy of the claim(s) to help support your case. In specific cases, you may need to provide supportive documentation, such as:

In order for us to review all of the facts supporting your case, it is in your best interest to submit the appropriate
supporting documentation for the patient's claim(s) in question. If supportive documentation is not submitted, the review will be conducted using information in our possession.

a. Written Requests

A Medicare Insurance Claim Review Request form (see section 18.4c) should be completed for each claim in question. (See section 18.3f on Multiple Requests for Review.)  Copies of this form can be printed from our website at www.hgsa.com, "For Health Professionals," under Printable Forms.

b. Fax Requests

This review request method is available only for electronic claim billers. Refer to section 18.3 for information on filing a request for a review. Providers should fax their inquiries to (717) 730-1601.

c. Telephone Appeals Request

This review request method is available by calling (717) 730-1455.

d. Appeals Process for Claims Denied due to Provider Billing Error

Ever-increasing costs associated with the written and telephone appeal process has forced Medicare to change our policy regarding reprocessing claims when the denial was due to a provider billing error.

Effective August 1, 1999, TAP representatives will no longer accept telephone appeals for provider billing errors involving the omission of claim data. Your office will have two options for denials due to the omission of claim data:

1. Correct the claim and resubmit for processing. It is not necessary to attach a Standard Paper Remittance (SPR) or an inquiry sheet with the claim submission. The appeal rights on the initial claim denial are still preserved. The corrected claim should be sent electronically. 

2. Submit a written appeal request. If you choose to exercise the written option, the following information is required in order to have your claim reviewed.

a. Submit the written appeal request within six months of the initial claim determination.

b. The written request must include a statement specifying what information you wish to correct and/or add to the initial claim submission, along with the appropriate documentation to support your request.

For example: If you want to add an additional diagnosis, include a statement indicating which diagnosis (in ICD-9 format) you want to add to the claim, along with the supporting note or records showing the correct diagnosis. Please reference your Medicare Part B Reference Manual, chapter 18 or the September 1999 Medicare Report regarding supporting documentation. Failure to include this information with your review request may result in an affirmation of the initial claims processing determination.

Note: It is not necessary to include a new HCFA-1500 (12-90) claim form; if you exercise your option to appeal the claim.

Many reporting errors cause claim denials due to the omission of supporting claim data. These include:

Claims that are denied due to the omission of supporting claim data can easily be corrected by resubmitting them with the additional data (i.e., modifier, correct diagnosis code, etc.). Medicare can then reprocess the claim based on this new data. Electronically resubmitted claims could be processed for payment within 14 days. If you current software does not offer a feature to allow for the resubmission of claim denials.

We encourage you to call the TAP lines for true appeals of initial claim determinations. These issues would include finalized claims where a reporting error or omission of claim data was NOT made on the claim. TAP will review these claims to ensure proper handling.

e. Electronic Requests

Medicare Provider Inquiry (MPI) is a free value-added software program that allows you to dial in for direct access to Medicare. You can check the status of your assigned claims, or review Medicare fees and policy, with Medicare Provider Inquiry, as well as electronically file claim review requests.

This service is only available to Medicare participating providers.

Note: For more information about Medicare Provider Inquiry, please call EDI Services at (717) 763-6722 (press option 1).

f. Multiple Requests for Review

If you have multiple claims for the same beneficiary which you would like reviewed, you need to complete only one Medicare Insurance Claim Review Request form; however, you must indicate on the form the Internal Control Number and the Medicare Health Insurance Claim (HIC) number of each claim you would like reviewed.

If you are requesting reviews for several beneficiaries for the same reason (e.g., same procedure code, same denial), you only need to complete one Medicare Insurance Claim Review Request form and attach a cover letter explaining the problem. Include dates of service, procedure codes and any other pertinent information. You may also attach a listing of all the beneficiaries' Health Insurance Claim numbers and internal control numbers of each claim, or include a copy of your summary voucher and highlight or note the specific claims.

18.4 Claim Reviews

a. Assigned Claims

You, your patient, or the patient's authorized representative may request a review of an assigned claim. If you request a review of your assigned claim, the response will be sent to you unless we are advised to send the response to another party.

b. Nonassigned Claims

You may request a review if the services were denied or reduced due to medical necessity guidelines. You may also request a review on behalf of the beneficiary if you have written authorization from the beneficiary to do so. The authorization from the beneficiary should include: 

Without authorization, only the beneficiary or the beneficiary's authorized representative may request a review of a nonassigned claim and receive a written response. The final response will be sent to the beneficiary or the beneficiary's representative, unless he or she advises us to respond to you or another party.

b.1 Beneficiary Authorization

For your convenience, we have developed a beneficiary authorization form that may be photocopied for use in your office. This form should be submitted when requesting a review on a service performed by your office.

b.1a Beneficiary Authorization for a Review Request form

Please see the following charts.

b.2 Authorized Representative

An individual appointed by the beneficiary to act as the representative of the beneficiary in conjunction with the beneficiary's claim or claims, is known as that beneficiary's authorized representative. The beneficiary has authorized his/her representative to make or give any request or notice; to present or to elicit evidence; to obtain information; and to receive any notice in connection with the claim or claims. This appointment must be accepted by the appointed individual.

Authorized representative requirements are met if a completed SSA Form 1696-U4 is submitted to the Medicare carrier. The form must be signed and dated by both the beneficiary and the representative. See section 18.4(b.2a).

Note: You may contact us on behalf of the beneficiary at anytime to provide additional information for review; however, in these cases, the review decision will be issued to the beneficiary only.

b.2a SSA Form 1696-U4 - Authorized Representative Requirements form

c. Medicare Insurance Claim Review Request Form

Sample of the Claim Review Request form in PDF format

18.5 Medicare Hearing Office

The Medicare program provides for the appeal of claim determinations. Before a hearing may be requested, a review of the claim must be completed by the carrier. If you are dissatisfied with the review determination on your claim, and the amount in dispute is $100 or more, you may request a hearing. You may combine claims that have been reviewed within six months of the fair hearing request to meet the $100 requirement.

ASSIGNED CLAIMS - You, your patient, or an authorized representative may request a hearing on an assigned claim. The hearing request must be written and signed by the person who desires the hearing. If the hearing is requested by an authorized representative (e.g., your billing agency or attorney), please be sure to include a completed "Appointment of Representative" form. These may be obtained from your local Social Security office.

NONASSIGNED CLAIMS - When the claim is nonassigned, you may request a hearing only if the services were denied or reduced on a medical necessity basis, and you are found to be liable for the denied or reduced service. You may also request a hearing if the enrollee appoints you as their representative and completes the "Appointment of Representative" form. The request must be in writing.

a. Types of Hearings

a.1 In Person

An in person hearing provides you the opportunity to appear, and to present oral testimony of witnesses, in addition to written documentation. However, the hearing is often difficult to schedule, expensive for you and the government.

In the event you choose to have an in-person hearing, the Hearing Officer will advise you, in writing, at least 2 weeks in advance of the scheduled hearing.

a.2 Telephone

If you wish to present testimony orally, but do not wish to appear, the telephone hearing may be the answer. It is not for everyone and it can never be substituted for an in-person hearing without your consent.

Telephone hearings do provide a convenient alternative to physicians and suppliers under severe time constraints or beneficiaries who want to testify but do not necessarily want to appear. It is a less expensive and easier to schedule alternative which you might want to consider, and one which has been used successfully by providers.

a.3 On the Record

If you do not wish to appear or present oral testimony, but are willing to let the facts speak for themselves, the on-the-record hearing is an alternative. It is the least expensive of the alternatives and usually results in prompt decisions. 

b. Filing a Fair Hearing Request

18.6 Administrative Law Judge

For services rendered on or after January 1,1987, you may request a hearing by an Administrative Law Judge (ALJ) in the event you are dissatisfied with the Hearing Officer's decision, and at least $500 remains in dispute. If the amount in dispute after the Hearing Officer's decision is less than $500, you may combine the case with other hearing decisions involving the same issues, laws, and facts that have been issued within 60 days to meet the $500 limit. The ALJ does not have the authority to overturn national coverage limitations made by the Health Care Financing Administration. However, if the appeal involves an assigned claim, and a medical necessity issue, the ALJ will determine whether the waiver of liability rules were applied correctly. An ALJ hearing must be requested in writing within 60 days of receipt of the Hearing Officer's decision. You may request an ALJ hearing by writing to the Hearing Office or through any Social Security Administration Office.

18.7 Review & Hearing Processing Times

Carriers are required to render a decision within 45 days for reviews and 120 days for hearings.

To help us meet these processing times, we are requesting that you furnish all supporting documentation at the time you file your appeal. For example, if your appeal involves a claim for hospital care, the hospital records should be sent along with your review.