Office of Medicare Hearings and Appeals (OMHA)

You are reading about Level 2 of the appeals process.

Who to Appeal to at Level 2 for Original Medicare (Parts A & B)

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You will be notified of the outcome of your Level 1 appeal (called a redetermination for Medicare Parts A & B) by mail. You will receive either a Revised Remittance Advice or a written Medicare Redetermination Notice (MRN). You may request a Level 2 appeal if you are not satisfied with the decision made in your Level 1 redetermination.

Who do you appeal to at Level 2 in Medicare Parts A & B?

A Qualified Independent Contractor (QIC), retained by CMS, will conduct the Level 2 appeal, called a reconsideration in Medicare Parts A & B. QICs have their own physicians and other health professionals to independently review and assess the medical necessity of the items and services pertaining to your case. You may file for a Level 2 appeal within 180 days of receiving the notice of redetermination. You will file your request with the QIC named on the notice.

Reconsiderations are conducted on-the-record and, in most cases, the QIC will send you a notice of its decision within 60 days of receiving your Medicare Part A or B request. The notice will contain detailed information about your right to appeal to OMHA (Level 3) if you are dissatisfied with the QIC’s decision. If the QIC is unable to make its decision within the required timeframe, they will inform you of your right to escalate your appeal to OMHA.

Special Circumstances

You may request an expedited reconsideration in Medicare Parts A & B if you are dissatisfied with a Quality Improvement Organization’s (QIO) expedited redetermination at Level 1. Expedited reconsiderations are conducted by qualified independent contractors (QICs).

To request an expedited reconsideration at Level 2, you must submit a request to the appropriate QIC no later than noon of the calendar day following your notification of the Level 1 decision. In most cases, the QIC will notify you of its decision on the reconsideration within 72 hours of receiving your request.

How to request a reconsideration

Your written request must be filed within 180 days of receiving your redetermination. To request a reconsideration, follow the instructions on your Medicare Redetermination Notice (MRN). Your written request for reconsideration must include:

• Medicare Health Insurance Claim (HIC) number;

• Specific service(s) and/or item(s) for which the reconsideration is requested;

• Specific date(s) of service;

• Your name and signature or your authorized or appointed representative; and

• Name of the organization that made the initial determination.

In addition to your request, you should clearly explain why you disagree with the Level 1 redetermination. Read the MRN carefully to see if any material was noted as missing. You need to enclose a copy of the MRN and any other information you want the QIC to review with your request. Additional material submitted after the request has been filed may delay the decision. Your written request and materials should be sent to the QIC identified in the MRN. The QIC can only consider information it receives prior to reaching its decision.

PLEASE SUBMIT ALL DOCUMENTS YOU THINK WILL SUPPORT YOUR CASE. IT WILL BE MORE DIFFICULT TO SUBMIT NEW EVIDENCE LATER. YOU MAY BE REQUIRED TO DEMONSTRATE GOOD CAUSE FOR SUBMITTING EVIDENCE FOR THE FIRST TIME AT THE ALJ LEVEL.

For more information about filing a Level 2 appeal, visit the "Appeals and Grievance" section of Medicare.gov.

If your Level 2 appeal was not decided in your favor and you still disagree with the decision, you may file a Level 3 appeal with OMHA if the amount remaining in controversy is $120 or more (in 2008).

You can download the Chart of the Appeals Process for Those with Original Medicare - Parts A & B [PDF - 56KB, DOC - 52KB]. The chart contains the overview for the entire appeals process for Original Medicare.

Please note that the Office of Medicare Hearings and Appeals is responsible only for the Level 3 claims appeals and certain Medicare entitlements and IRMAA 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.