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In most cases, the ALJ will issue a decision within 90 days of receipt of the request for hearing. The time limit may be extended for a variety of reasons, including but not limited to: The case being escalated from the reconsideration level; The submission of additional evidence that was not included with the hearing request; Request for an in-person hearing; The appellant's failure to send notice of the hearing request to other parties; and The initiation of discovery in cases where CMS is a party. If the ALJ does not issue a decision within the applicable adjudication timeframe, the appellant may request that the ALJ escalate the case to the Appeals Council level. Fourth Level of Appeal – Appeals Council Review A party to the ALJ hearing may request Appeals Council review of the ALJ’s decision or dismissal. The request for Appeals Council review must be filed within 60 calendar days of receipt of the ALJ’s decision, which provides information about how to file a request for a review. The request for an Appeals Council review must specify the issues and findings that are being contested. At this level of appeal, there is no AIC requirement. In most cases, the Appeals Council will issue a decision within 90 days of receipt of the request for review. The 90-day timeframe may be extended for various reasons including, but not limited to, the case being escalated from an ALJ hearing. If the Appeals Council does not issue a decision within the applicable timeframe, the appellant may request that the Appeals Council escalate the case to the Judicial Review level. Fifth Level of Appeal – Judicial Review A party to a final decision of the Appeals Council may request judicial review before a U.S. District Court judge if the AIC requirement is met and is still in controversy. The AIC will be adjusted annually in accordance with the percentage increase in the medical care component of the CPI-U. The appellant must file the request for review within 60 days of receipt of the Appeals Council’s decision, which provides information about how to request judicial review. Medicare Physician Guide: A Resource for Residents, Practicing Physicians and Other Health Care Professionals 75
Liability and Appeal Decisions Liability regarding appeal decisions is as follows: When an original claim determination for both assigned and nonassigned claims is upheld on a review and the provider or supplier knew or could have been expected to know that payment for the service might be denied or reduced, he or she is held liable and must refund any monies collected from the beneficiary within 30 days of the review decision unless a valid Advance Beneficiary Notice was properly executed. When an original claim determination for an assigned claim is upheld on a review and the provider or supplier and beneficiary could not have been expected to know that payment for the service might be denied or reduced, payment is made to the provider or supplier. When an original claim determination for a nonassigned claim is upheld on a review and it is found that the provider or supplier could not have been expected to know that payment for the service might be denied or reduced, he or she is notified that payment may be collected from the beneficiary. If the beneficiary is found liable, a letter is sent indicating that he or she is responsible for payment. When an original claim determination for a nonassigned claim is upheld on a review and it is found that neither the provider or supplier nor the beneficiary could have been expected to know that payment for the service might be denied or reduced, neither party will be responsible for payment. When the beneficiary is not responsible for the payment of a service, the provider or supplier must refund any monies collected from the beneficiary. If the refund is not made within the specified time limits, the following actions may occur: o For an assigned claim, the beneficiary may submit a request to Medicare for indemnification from payment. A letter is sent to the provider or supplier indicating that a refund must be made to the beneficiary within 15 days for the amount actually paid, including any amounts applied to deductibles, coinsurance, and copayments. If the refund is not made within 15 days, Medicare will pay the beneficiary and request a refund from the provider or supplier. o For a nonassigned claim, the beneficiary may notify Medicare that the provider or supplier did not refund the amount due. A letter is sent to the provider or supplier indicating that a refund is due to the beneficiary within 15 days. If a refund is not made within 15 days, the provider or supplier may be subject to Civil Monetary Penalties and sanctions. Reopenings A reopening is a remedial action taken to change a final determination or decision that resulted in either an overpayment or underpayment, even though the determination or decision was correct based on the evidence of record. A reopening allows the correction of minor errors or omissions without initiating a formal appeal. If a claim is denied Medicare Physician Guide: A Resource for Residents, Practicing Physicians and Other Health Care Professionals 76
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Medicare Physician Guide A Resource
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ICD-9-CM Notice The International C
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MEDICARE PHYSICIAN FEE SCHEDULE ...
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CHAPTER ONE INTRODUCTION TO THE MED
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THE MEDICARE PROGRAM The Medicare P
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worker must have a specified number
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Part B - Medical Insurance Some of
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Where to Find Additional Informatio
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CMS contracts with one Quality Impr
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This chapter discusses Medicare pro
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staff or faculty appointments, part
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The following forms are often requi
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Problem Focused Examination - shoul
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Cardiovascular Examination System/B
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System/Body Area Gastrointestinal (
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Physician

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