RAC Appeals Process Resources

On May 17, 2009, in Documents, by AQ-IQ LLC

The RAC Appeals Process is not too different from Medicare’s standard Appeals Process. CMS offers this explanation of the process. 

We have pulled out the most useful links for providers:

New Final Rule dated January 17, 2017 updates portions of the Appeals Process. Read the Rule in the Federal Register. 

A booklet from MLN explaining the appeals process.

Flow chart describing the process.

CMS web page for the Appeals Process.

Qualified Independent Contractors The Medicare, Medicaid, and CHIP Benefits Improvement and Protection Act (BIPA) of 2000 included provisions aimed at improving the Medicare appeals process.  Part of these provisions mandate that all second-level appeals, also known as reconsiderations, be conducted by Qualified Independent Contractors (QICs). Download this fact sheet for more information on QICs.

Medicare Appeals and Grievances: provides a short explanation as to how to file an appeal or grievance if you have a complaint.

Medicare Appeals Forms
Form Number Form Information
CMS-1696 Appointment of Representative You should use this form if you want to name someone to represent you to help appeal your claim.View Form in Adobe PDF (Size: 120 KB)
View Spanish Form in Adobe PDF (Size: 145 KB)
CMS-20031 Transfer of Appeal Rights Use this form to transfer your appeal rights to your provider or supplier. Your provider or supplier may not have the right to appeal your claim in some situations. View Form in Adobe PDF (Size: 36 KB)
CMS-20027 Medicare Redetermination Request Form If you don’t agree with the initial claim decision by Medicare, you should use this form to appeal your claim. This is called a redetermination and is the first level of the appeals process. This is done by the Medicare Contractor who processed your claim. Any dollar amount can be appealed at this level, but it needs to be submitted within 120 days from the date you received the initial claim decision. This is normally the date shown on your Medicare Summary Notice (MSN). To file an appeal, you can also follow the instructions on your MSN by signing and returning the notice to the Medicare Contractor who processed your claim.View Form in Adobe PDF (Size: 50 KB)
CMS-20033 Medicare Reconsideration Request Form Use this form if you are dissatisfied with the redetermination decision made during your first level of appeal. This form is used for the second level of appeals for your claim. This request is called a reconsideration and is done by a Qualified Independent Contractor (QIC). Any dollar amount can be appealed at this level, but it needs to be submitted within 180 days from the date of your redetermination decision. View Form in Adobe PDF (Size: 48 KB)
CMS-20034A/B Request for Medicare Hearing by an Administrative Law Judge Use this form is you are dissatisfied with the QIC reconsideration decision made during your second level of appeal. This form is used to request a hearing by an Administrative Law Judge (ALJ). This is the third level of appeals. This request needs to be submitted within 60 days from the date of your reconsideration decision. The claim(s) you are appealing must be more than $120.View Form in Adobe PDF (Size: 85 KB).
 

Comments are closed.