The Medicare appeal process starts with a review by the plan sponsor, but their decision can be reconsidered by an independent review entity. There can also be further reviews by an administrative law judge, a Medicare appeals council, and finally by federal district court judge.
1. Redetermination by your plan
The plan must respond within 7 days; however, they must respond within 72 hours if your doctor certifies that the review should be expedited.
2. Reconsideration by the independent review entity
You may request reconsideration within 60 days of the redetermination by your plan. This entity must consult your doctor about why the exception is needed. The review must be completed within 7 days of your request, but within 72 hours if your doctor certifies that the review should be expedited.
3. Administrative law judge (ALJ) hearing
If the independent review entity denies your request, and your request involves at least $130 in costs projected out over a year, you may request a hearing before an ALJ, who should make a decision within 90 days
4. Medicare appeals council
You may ask the Medicare appeals council to review an ALJ decision within 60 days of the decision. This review council will accept review under limited circumstances.
5. Judicial review
If the appeals council decision is unfavorable, you may seek judicial review in federal court, within 60 days of the Medicare appeals council’s decision, if your claim involves at least the minimum level Medicare will set every year.