Module 1, Topic 1
In Progress

Day 6: Five Levels of Appeal Part 1

Petria September 3, 2020

The Five Levels of Appeal – Part 1

Common Rejection Problems, issues, challenges

  • Requirements of face to face not met
  • Requested medical records not submitted in timely manner
  • Information provided doesn’t support medical necessity
  • Appropriate OASIS not submitted
  • POC/certification signed but not dated

Requested medical records not submitted in timely manner:

  • Provider has 30 days from the time Additional Development Request was generated to respond:
  • Clerical assignment to log in and track
  • Set deadline 72 hours before true deadline and live by it!
  • Establish a uniform process that ensures you have time to review the documents before sending them.
  • Monitor your direct data entry (DDE)
  • Always attach copy of ADR request to top of what is sent.



CMS ADR Edit Types

  • Probe
    • Service
    • HIPPS
    • Physician
    • Diagnosis
    • CBSA
  • Provider
  • Beneficiary
  • Late OASIS submissions (RAC rationale handout)



Charge Denial Rate

(CDR) = Total charges denied/down coded on the number of claims received divided by / Total charges on the number of claims reviewed
multiplied by 100



Probe Sample Edit

Probe sample edit will consist of 20-40 claims

25 claims @ $2,000 each = $50,000

Therefore, if you reach $5,000 in denied and/or down coded claims you will be at 10%.

Ex.: 3 denied claims are $6,000 which is 12% (6000 ÷ 50000 = 0.12)



Claim Denial Rate

Low CDR 0%-9% – medical review discontinued

Low CDR 10%-15% – medical review discontinued, education provided, possible re-probe in six months

Moderate CDR 16%-50% – medical review resumed

Moderate CDR 16%-50% – medical review resumed, after two quarters, a written corrective action plan (CAP) requested

High CDR 51%-100% – medical review resumed, written CAP requested



Claim Denial Rate

After one year of medical review with limited or no improvement, the provider may be referred for program exclusion, suspension of payment, civil monetary penalty, benefits integrity unit referral, comprehensive medical review, and/or withholding of RAP payments.



ADR (Additional Development Request)/Medical Review

In DDE (Direct data Entry) go to 01 then 12 and enter S B6001 in the Status/Location (S/LOC) field to look up possible ADRs the provider did not receive in the mail

Check this on a weekly basis


Five Levels of Appeals

  • MAC (Medicare Administrative Contractor)
  • QIC (Qualified Independent Contractors)
  • ALJ (Administrative Law Judge)
  • MAC (Medicare Appeals Council)
  • U.S. District Court


Five Levels of Appeals

  • Level 1 is a Redetermination, which is conducted by the MAC. A Redetermination is a completely new, critical re-examination of a disputed claim or charge.  MACs have 60 days to complete a redetermination. If additional documentation is required, the processing time is 74 days from the date of the initial receipt.
  • Level 2 is a Reconsideration. This appeal is conducted by the Quality Independent Contractor (QIC). You may only file a Reconsideration after you have submitted a Redetermination and received a response. All Reconsideration requests must be submitted in writing to the QIC within 180 days of receiving the redetermination letter. The QIC has 60 days to render a reconsideration decision.
  • Level 3 is filing an appeal with the Administrative Law Judge (ALJ). ALJs hold hearings and issue decisions related to Medicare coverage determination that reach Level 3 of the Medicare claims appeal process.
  • Level 4 is the Department Appeals Board (DAB) Review. The DAB provides impartial, independent review of disputed decisions in a wide range of Department programs under more than 60 statutory provisions.
  • Level 5 is the Federal Court (Judicial) Review.