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 Council review. The Council may also undertake review of an ALJ decision on its own motion. Final Council decisions may be appealed to federal court if amount in controversy requirements are met.
Filing an Appeal
Beginning July 1, 2005, the procedures that govern appeals to the Council 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.
Representative Fees
A representative of a beneficiary who wishes to charge a fee for services in connection with an appeal before the Council 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).
Contact Information
Toll free: 1-866-365-8204
Local: 202-565-0100
Fax: 202-565-0227
Department of Health & Human Services
Departmental Appeals Board, MS 6127
Medicare Operations Division
330 Independence Ave., S.W.
Cohen Building, Room G-644
Washington, DC 20201