Carrier appeals process for redeterminations
The Medicare Part B appeals process for redeterminations (first appeal level) changed for services processed on or after January 1, 2006. If you disagree with the initial claim determination, regardless of the amount in controversy, you must first request a redetermination with the carrier. All documentation should be submitted with your request for a redetermination.
For redeterminations, the second level of appeal is now called a reconsideration (formerly a Hearing). Requests must be made within 180 days from the date of the redetermination. Reconsiderations (second appeal level) are performed by CMS-contracted entities called Qualified Independent Contractors (QICs) instead of the carrier or a contracted Hearing Officer. The QIC for Florida is Q2 Administrators; their address and reconsideration request form can be found in the Part B Forms section.
The amounts in controversy for Administrative Law Judge (ALJ, third appeal level) and Federal Court Review (fifth appeal level) typically change each year on January 1. Refer to the chart below for the current threshold amounts.
There are still five levels of appeal, and providers still must progress through the appeals process one step at a time and within the applicable time frames and monetary thresholds. It is important to follow instructions received with your redetermination decision letter. All information on where to request the next level of appeal will be provided to you within that letter.
The five levels of appeal are as follows:
1st Level - Redetermination
Time limit to file request: 120 days from date of receipt of the initial determination notice
Monetary threshold: None
Request is sent directly to the carrier
2nd Level - Reconsideration
Time limit to file request: 180 days from date of receipt of the redetermination
Monetary threshold: None
Request is sent directly to the QIC
3rd Level - Administrative Law Judge (ALJ) Hearing
Time limit to file request: 60 days from the date of receipt of the reconsideration
Monetary threshold: At least $130.00 remains in controversy (requests filed on or after January 1, 2010).
4th Level - Departmental Appeals Board (DAB) Review
Time limit to file request: 60 days from the date of receipt of the ALJ hearing decision
Monetary threshold: None
5th Level - Federal Court Review
Time limit to file request: 60 days from date of receipt of DAB decision or declination of review by DAB
Monetary threshold: At least $1,350.00 remains in controversy for requests filed on or after January 1, 2012; $1,300.00 for requests filed prior to January 1, 2012.
Overpayment appeals address
The address for overpayment appeals is as follows:
First Coast Service Options Inc.
Overpayment Redetermination (Review Request)
P.O Box 45248
Jacksonville, FL 32232-5248
Note: It is very important that overpayment appeals are sent to the correct address to ensure proper handling.
The Medicare Part B appeals process for redeterminations (first appeal level) changed for services processed on or after January 1, 2006. If you disagree with the initial claim determination, regardless of the amount in controversy, you must first request a redetermination with the carrier. All documentation should be submitted with your request for a redetermination.
For redeterminations, the second level of appeal is now called a reconsideration (formerly a Hearing). Requests must be made within 180 days from the date of the redetermination. Reconsiderations (second appeal level) are performed by CMS-contracted entities called Qualified Independent Contractors (QICs) instead of the carrier or a contracted Hearing Officer. The QIC for Florida is Q2 Administrators; their address and reconsideration request form can be found in the Part B Forms section.
The amounts in controversy for Administrative Law Judge (ALJ, third appeal level) and Federal Court Review (fifth appeal level) typically change each year on January 1. Refer to the chart below for the current threshold amounts.
There are still five levels of appeal, and providers still must progress through the appeals process one step at a time and within the applicable time frames and monetary thresholds. It is important to follow instructions received with your redetermination decision letter. All information on where to request the next level of appeal will be provided to you within that letter.
The five levels of appeal are as follows:
1st Level - Redetermination
Time limit to file request: 120 days from date of receipt of the initial determination notice
Monetary threshold: None
Request is sent directly to the carrier
2nd Level - Reconsideration
Time limit to file request: 180 days from date of receipt of the redetermination
Monetary threshold: None
Request is sent directly to the QIC
3rd Level - Administrative Law Judge (ALJ) Hearing
Time limit to file request: 60 days from the date of receipt of the reconsideration
Monetary threshold: At least $130.00 remains in controversy (requests filed on or after January 1, 2010).
4th Level - Departmental Appeals Board (DAB) Review
Time limit to file request: 60 days from the date of receipt of the ALJ hearing decision
Monetary threshold: None
5th Level - Federal Court Review
Time limit to file request: 60 days from date of receipt of DAB decision or declination of review by DAB
Monetary threshold: At least $1,350.00 remains in controversy for requests filed on or after January 1, 2012; $1,300.00 for requests filed prior to January 1, 2012.
Overpayment appeals address
The address for overpayment appeals is as follows:
First Coast Service Options Inc.
Overpayment Redetermination (Review Request)
P.O Box 45248
Jacksonville, FL 32232-5248
Note: It is very important that overpayment appeals are sent to the correct address to ensure proper handling.
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