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Medicare may use contractors to help process appeals. You have the right to file a Medicare appeal if you feel that Medicare (or a Medicare health plan or prescription drug plan) has denied you coverage of an item or service, or covered less of the cost than you feel you should get.
A Medicare contractor may review your appeal.
If you’re enrolled in Original Medicare (Part A and Part B), your Medicare appeals process typically starts with a Medicare Administrative Contractor, or MAC. Even though Medicare is a federal program, it pays claims and administers benefits through a network of private companies to help control expenses and improve service. If you want to understand the Medicare appeals process, the first step is to understand Medicare contractors and their role in handling your claims.
What are Medicare contractors, and can they help with Medicare appeals?
Medicare contractors, also known as Medicare administrative contractors, were hired to reduce administrative problems and modernize the claims and appeals processing system. Streamlining Medicare appeals and claims was a goal of the Medicare Modernization Act (MMA) of 2003. Until then, Medicare claims were handled by Medicare Part A fiscal intermediaries and Part B carriers.
There are two main types of Medicare administrative contractors (MAC):
- A/B MACs, who handle Medicare Part A and Part B claims and Medicare appeals for inpatient and outpatient care and services, as well as hospice and home health care.
- DME MACs, who handle claims and Medicare appeals for durable medical equipment (DME), orthotics, and prosthetics.
What do Medicare contractors do besides process Medicare appeals and claims?
The congressional mandate for Medicare administrative contractors includes more than just Medicare appeals and claims. These Medicare contractors handle most of the administrative burden for managing the Medicare program, including:
- Processing and accounting for Medicare payments to individuals and providers
- Handling redetermination requests, the first stage of the Medicare appeals process
- Enrolling new providers and handling their questions and concerns
- Helping providers get paid for their services
- Training providers about Medicare billing
- Investigating Medicare fraud
- Auditing institutional provider cost reports
- Coordinating with Medicare fee-for-service contractors and Centers for Medicare and Medicaid Services (CMS), the agency responsible for the Medicare program
How do Medicare contractors handle Medicare appeals?
Medicare contractors are involved in the first step of the Medicare appeals process, which is to request a redetermination if you don’t agree with a decision made by Medicare. You or your representative must complete a redetermination request and send it to the Medicare administrative contractor for your area (you can find the address on the back of your Medicare Summary Notice, or MSN).
Once the Medicare contractor receives your Medicare appeals request and reviews any supporting documentation you send, the contractor has 60 days to make a decision and send you a Medicare Redetermination Notice. If you are unhappy with their decision, you can move to Level 2 in the Medicare appeals process, which is a Medicare Reconsideration Request. You have 180 days to request reconsideration of the Medicare contractor’s decision.
At this stage, Medicare appeals are no longer handled by the Medicare administrative contractor. Your reconsideration request is sent to a Qualified Independent Contractor, or QIC; your Medicare Redetermination Notice will include information on where to send your Level 2 request.
Medicare uses QICs to assist with the Medicare appeals process. These contractors have their own independent doctors and health professionals review your reconsideration request and prepare a decision. The QICs are not affiliated with the Medicare administrative contractors, and do not participate in the first step of the Medicare appeals process, the redetermination request; QICs are hired to provide an independent opinion about your claim.
Do Medicare contractors handle Medicare appeals for Medicare Advantage plans?
Medicare administrative contractors only handle the first stage of appeals for those receiving benefits through Medicare Part A and Part B. If you have a Medicare Advantage plan, your plan is administered by a private insurance company contracted with Medicare, and your Medicare appeals go through the plan organization during the first stage of the process. If your plan issues a payment denial notice, you’ll find instructions for appealing that decision in the notice. The same applies for stand-alone Medicare Part D Prescription Drug Plans, which are also administered by private insurance companies approved by Medicare.
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