There are five levels of Medicare appeals:
- The first level appeal is called a request for reconsideration and is done by the health plan.
- If your health plan does not change its decision, then the health plan must send your case file to Maximus for a second level appeal, called an External Review.
- If Maximus agrees with the health plan, you may try the third level appeal, called an Administrative Law Judge Hearing (ALJ Hearing).
- If you are unhappy with the ALJ Hearing decision, you may ask the Medicare Appeals Council (Council) to review your case. This is called a Council Review; it is the fourth level appeal.
- If you are unhappy with the Council Review, you may ask a Federal Court Judge to review your case, This is the fifth level appeal.
Each of these levels has steps that you and your health plan must follow. In each of these five levels of appeal:
- You have the right to have someone help you with your appeal. You can pick anyone you want, such as a friend, family member, doctor, or lawyer.
The First Level Appeal: Health Plan Reconsideration
If you requested services or payment from the plan and the plan decided to deny all or part of what you requested, you can ask the plan to reconsider their decision. This is called an appeal or request for reconsideration.
The Second Level Appeal: External Review
If your health plan does not change its decision after your request for reconsideration, the plan automatically sends your case file to Maximus for an External Review.
The external review by Maximus includes:
- Maximus sends you and your representative (if you have one) a letter telling you that they have your case file.
- Maximus carefully reviews
- Medicare rules
- Your agreement with the health plan,
- All the information in your case file, and
- Any additional information that you provide
- Maximus makes a decision in
- 72 hours, or up to 17 days in certain cases, for an expedited (fast) review
- 30 to 44 days for health care you are waiting for
- 30 to 60 days for payment of a denied bill.
- Maximus sends you a letter with the decision.
- If Maximus disagrees with the plan (overturns the plan's denial), then Maximus will send a letter to you and a letter to your health plan telling your health plan to pay for or provide for your health care.
- If Maximus agrees with your health plan (upholds the plan's denial), your letter will tell you what you can do. If you want to appeal this decision, you can ask for the third level appeal, an ALJ Hearing.
Your Rights in an External Review with Maximus:
Medicare Managed Care & PACE Reconsideration Project
3750 Monroe Avenue
Pittsford, NY 14534-1302
- You have the right to send us information about your case. We must get this information 10 days after the date you receive Maximus' letter telling you we have your case file. You can have someone such as a family member, friend, or doctor help you write this information. Please include your name and appeal number on your information. Send your information to:
- You have the right to ask for Maximus letters in a language you understand.
- You have the right to a copy of everything in your file.
- You have the right to receive a written appeal decision from Maximus.
The Third Level Appeal: ALJ Hearing
If Maximus agrees with your health plan but not with you, you can ask for a hearing with an Administrative Law Judge (ALJ). If you ask for a hearing, an ALJ from the Office of Medicare Hearings and Appeals will decide your case. You can learn more about the ALJ hearing process by visiting www.cms.gov/medicare/appeals-grievances/fee-for-service/third-level-appeal.
You can ask for an ALJ Hearing if the amount of money at stake in your appeal satisfies the Amount in Controversy (AIC) requirement that CMS establishes annually. For 2023, that amount is $180. To find out more about the AIC please visit: http://www.hhs.gov/omha
Write to Maximus and ask for an ALJ Hearing. You have to write and ask for an ALJ Hearing within 60 days of the date of the decision.
- The Office of Medicare Hearings and Appeals will schedule your hearing, and will tell you the time and place of the hearing.
- You participate in the hearing and give information about your case. Your health plan may also have someone at the hearing to give information. You can include anyone to speak for you or help you. This person does not have to be a lawyer. You can pick anyone, such as a family member, friend, or doctor.
- The ALJ makes a decision based on your case file and the information given at the hearing.
- The ALJ sends the written decision to you, your health plan, and to Maximus.
- If the ALJ agrees with you, then Maximus will send a letter to your health plan telling them to pay or provide for your health care.
The Fourth Level Appeal: Medicare Appeals Council Review
If you are unhappy with the decision made by the ALJ, you may be able to ask for Medicare Appeals Council review of your case. This board is part of the federal department that runs the Medicare program.
The Fifth Level Appeal: Federal Court
If you are unhappy with the decision made by the Medicare Appeals Council, you may be able to take your case to a federal court. For appeals filed during calendar year 2023, the dollar value of your medical care must be at least $1,850 to go to federal court.
More about your rights and who can help you
To get more information about your appeal rights:
- Visit the Medicare Appeal web site (www.medicare.gov)
- Talk to your health plan about how to file appeals and your rights.
To get help with your appeal:
- Call your local Bar Association or legal aid program. If you do not have much money, these offices may be able to help you with your appeal.
- Talk to a private lawyer who may charge you a fee.
- Call 1-800-MEDICARE to request the telephone number of your State Health Insurance Assistance Program.
For information about the availability of auxiliary aids and services, please visit: