Medicare Operations Division
The Medicare Operations Division provides staff support to the Administrative Appeals Judges (AAJs) and Appeals Officers (AOs) on the Medicare Appeals Council (MAC). The MAC provides the final administrative review of claims for entitlement to Medicare and individual claims for Medicare coverage and payment filed by beneficiaries or health care providers/suppliers.
The Social Security Administration (SSA) makes the initial determination on a claim for entitlement to Medicare. A contractor of the Centers for Medicare & Medicaid Services (CMS), including a Medicare Advantage organization, makes an initial determination on an individual claim for Medicare coverage and payment. On appeal, an Administrative Law Judge (ALJ) provides a hearing. If dissatisfied with an ALJ decision or dismissal, the parties to the ALJ hearing may request MAC review. The MAC may also undertake review of an ALJ decision on its own motion. Final ALJ or MAC decisions may be appealed to federal court if certain "amount in controversy" requirements are met.
Filing an Appeal
Beginning July 1, 2005, the procedures that govern appeals to the MAC differ depending on which CMS contractor made the determination that was appealed to the ALJ. The procedures also differ depending on whether the ALJ issued a decision or a dismissal order.
- If an ALJ issued a decision or dismissal for a claim for Part D drugs, other than a claim solely for payment of Part D drugs already furnished, an enrollee may request that his or her request for review be expedited. If you wish to expedite review, these procedures apply to your appeal.
- If an ALJ issued a decision after a Qualified Independent Contractor, Quality Improvement Organization, or Independent Review Entity made a reconsideration determination, these procedures apply to your appeal.
- If an ALJ issued a dismissal order after a Qualified Independent Contractor, Quality Improvement Organization, or Independent Review Entity, made a reconsideration determination, these procedures apply to your appeal.
- If you are not sure which procedures apply, please follow these instructions to appeal. We will apply the right procedures to your case.
A representative of a beneficiary who wishes to charge a fee for services in connection with an appeal before the MAC must obtain approval of the fee, 42 C.F.R. § 405.910.
Further information on fee approval is on the back of the Form CMS-1696 (07/05), used to appoint a representative. The Form SSA-1560-U4 (02/05), or any other writing that provides the information requested in 20 C.F.R. § 404.1725(a), may be used to request approval of a representative's fee. The Medicare Appeals Council will consider the request for fee approval using the criteria in 20 C.F.R. § 404.1725(b).