The following describes how payment decisions are made and where you make your Level 1 appeal (text only version).
Your doctor or hospital submits a bill to Medicare
Medicare contracts with private companies ("contractors") to process medical claims (bills) for health care items and services provided to Medicare beneficiaries.
A determination is made on how much Medicare will pay.
After a claim is sent to the appropriate contractor, the contractor must:
- Determine if the items and services on the claim are covered or reimbursable by Medicare;
- Calculate any amount that is payable by Medicare;
- Make the payments to health care provider(s) who furnished the items or services; and
- Notify you of its decision to pay or deny coverage or payment for specific items or services.
The contractor will send you a Medicare Summary Notice. The notice will also tell you why your claim was not paid and what appeal steps you can take.
If you disagree with the Medicare contractor's decision on your claim, you have the right to file an appeal.
Appeal the claims decision. **
Level 1 Appeal: "redetermination"
The first level of an appeal for Original Medicare is called a redetermination. A redetermination is performed by the same contractor that processed your Medicare claim. However, the individual that performs the appeal is not the same individual that processed your claim. The appeal is a new and independent review of your claim.
** Special Circumstances for Expedited Review
You may request an expedited determination by a Quality Improvement Organization (QIO) if you disagree with the provider's decision to discharge services or the decision to terminate services and your physician certifies that failure to continue the services places your health at significant risk. To request an expedited determination by a QIO, you must submit a request for a determination to the QIO in the State in which you are receiving the provider services by no later than noon of the calendar day following receipt of the provider's notice of termination. In most cases, the QIO will notify you of its decision on the determination within 72 hours of receiving your request.
For more information:
- See the Medicare Summary Notice you received in the mail; your appeal rights are on the last page or back. You can request an appeal within 120 days from the date you received the Medicare Summary Notice.
- Visit the "Claims and Appeals" section of Medicare.gov.
Please note that the Office of Medicare Hearings and Appeals is responsible only for the Level 3 claims appeals and certain Medicare entitlement appeals and Part B premium appeals. OMHA is not responsible for levels 1, 2, 4, and 5 of the appeals process. OMHA provides additional information on other levels of appeals to help you understand the appeals process in a broad context.
