Medicare Appeals Procedures
If an ALJ issued a decision after a Qualified Independent Contractor, Independent Review Entity (IRE), or Quality Improvement Organization made a reconsideration determination, these procedures apply to your appeal:
If you do not agree with the Administrative Law Judge’s (ALJ’s) decision, you may appeal to the Medicare Appeals Council (the Council). Other parties may appeal too. We call an appeal to the Council a “request for review.” The Medicare agency may also ask the Council to review the ALJ’s decision.
If no party appeals and the Council does not review the ALJ’s decision at the request of the Medicare agency, the ALJ’s decision is binding on all parties. You will have no right to ask a federal court to review the ALJ’s decision.
You may appoint an attorney or other person to represent you. Some legal aid groups may provide legal services at no charge.
What to Include in Your Appeal
Your appeal must identify the parts of the ALJ’s decision with which you disagree, and explain why you disagree. For example, if you believe that the ALJ’s decision is inconsistent with a statute, regulation, Medicare agency ruling, or other authority, you should explain why the ALJ’s decision is inconsistent with that authority.
You should use form DAB-101 to appeal. Your appeal may also be made in writing. Your written appeal must include:
- the beneficiary's name;
- the beneficiary's health insurance claim number;
- the item or service in dispute;
- the date of the item or service;
- the date of the ALJ’s decision; and
- your name and signature, and, if applicable, the name and signature of your representative.
You must send a copy of the ALJ’s decision with your appeal.
How to File an Appeal
Your appeal must be filed, i.e. received by the Council, within 60 days after you receive ALJ’s decision. The Council will assume that you received the ALJ’s decision five days after the date shown on it, unless you show that you received it later. If you file the appeal late, you must show that you had good cause.
Mail the appeal to:
Department of Health and Human Services
Departmental Appeals Board, MS 6127
Medicare Appeals Council
330 Independence Ave., S.W.
Cohen Building, Room G-644
Washington, D.C. 20201
Or you may fax the appeal to (202) 565-0227. If you send a fax, please do not also mail a copy. You must send a copy of your appeal to the other parties and indicate that all parties, including all beneficiaries, have been copied on the request for review. For claims involving multiple beneficiaries, you may submit a copy of the cover letters issued or a spreadsheet of the beneficiaries and addresses who received a copy of the request for review.
The Medicare regulations at 42 C.F.R. Part 405, Subpart I, apply to this case. Medicare agency rulings may also apply. If you have questions about the Council, you may call (202) 565-0100.
Medicare Appeals Council Action
The Council will limit its review to the issues raised in the appeal, unless the appeal is filed by an unrepresented beneficiary. The Council may change the parts of the ALJ’s decision that you agree with. The Council may adopt, change, or reverse the ALJ’s decision, in whole or in part, or it may send the case back to an ALJ for further action. The Council may also dismiss the appeal to the ALJ or the appeal to the Council.