Legal Authorities
The current Medicare appeals process was established by various statutes and implementing regulations. The table below lists some of the statutes and regulations that govern the appeals process for Medicare claims and entitlement, Medicare Advantage organization determination, and Medicare prescription drug coverage determination appeals, as well as select OMHA and Centers for Medicare & Medicaid (CMS) program guidance.
| Medicare Part | Statute* | Implementing Regulations | Select Program Guidance |
|---|---|---|---|
| Medicare Part A and Part B fee-for-service claim, entitlement, and certain premium initial determinations |
Social Security Act QIO Appeals Only |
42 C.F.R. part 405, subpart I (§§ 405.1000–405.1063 for ALJ appeals) QIO Appeals Only 42 C.F.R. part 478, subpart B (§ 478.40 for ALJ appeals) IRMAA Appeals Only 20 C.F.R. §§ 418.1301–418.1355 (§ 418.1350 for ALJ appeals) |
OMHA Case Processing Manual (For prior versions, see the 2017 Case Processing Manual; Division II for Part A/B appeals, Division V for entitlement and certain premium appeals) Medicare Claims Processing Manual, CMS Publ’n 100-04, Ch. 29 (§§ 330–330.6 for ALJ appeals) |
| Medicare Part C Medicare Advantage and competitive health plan organization determinations | Social Security Act § 1852(g) (42 U.S.C. 1395w-22(g)) Social Security Act § 1876(c)(5)(B) (42 U.S.C. 1395mm(c)(5)(B)) |
42 C.F.R. part 422, subpart M (§§ 422.600–405.612 for ALJ appeals) 42 C.F.R. part 417, subpart Q
|
OMHA Case Processing Manual (For prior versions, see the 2017 Case Processing Manual; Division III for Part C appeals) Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance (§§ 70–70.4.3 for ALJ appeals) |
| Medicare Part D plan sponsor coverage determinations and certain premium determinations | Social Security Act § 1860D-4 (42 U.S.C. 1395w-104) |
42 C.F.R. part 423, subparts M and U (§§ 423.1968–423.2063 for ALJ appeals) IRMAA Appeals Only 20 C.F.R. §§ 418.2301–418.2355 (§ 418.2350 for ALJ appeals) |
OMHA Case Processing Manual (For prior versions, see the 2017 Case Processing Manual; Division IV for Part D appeals) Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance (§§ 70–70.4.3 for ALJ appeals) |
*Statutory citations are given to the Social Security Act, as amended, with United States Code (U.S.C.) equivalents as parentheticals. However, please note that the online version of the U.S.C. may be more current than the online version of the Social Security Act.
The CMS Administrator also issues Rulings that serve as precedent final opinions and orders and statements of policy and interpretation. CMS Rulings are binding on all CMS components and OMHA adjudicators.
The Chair of the Departmental Appeals Board (DAB) may designate certain Medicare Appeals Council decisions as precedential. These precedential decisions are binding on all HHS components, including OMHA adjudicators.
