Scheme Nickname: 
Health Insurance Benefits Under the Medicare Programs

HHS administers healthcare insurance benefits under the Medicare Program. There are four distinct health insurance programs within the Medicare program and each has its own appeals process. These health insurance programs are referred to as "parts." Only certain parts of the programs benefits are adjudicated (Parts A, B and D). Claimants appeal adverse initial determinations to the Office of Medicare Hearings and Appeals. However, the Office of Medicare Hearings and Appeals is only responsible for Level 3 of the Medicare claims appeal process and certain Medicare entitlement appeals and Part B premium appeals. ALJs hear these cases and claimants may appeal adverse ALJ decisions to the Departmental Appeals Board's Medicare Appeals Council.

Comments/Notes on Adjudication Structure: 
This describes the adjudication scheme for Medicare Appeals: Once an initial claim determination is made, beneficiaries, providers, and suppliers have the right to appeal Medicare coverage and payment decisions. Section 1869 of the Social Security Act and 42 C.F.R. part 405 subpart I contain the procedures for conducting appeals of claims in Original Medicare (Medicare Part A and Part B). 42 CFR Part 423, There are five levels in the Medicare Part A and Part B appeals process. The levels are: First Level of Appeal: Redetermination by a Medicare carrier, fiscal intermediary (FI), or Medicare Administrative Contractor (MAC). Second Level of Appeal: Reconsideration by a Qualified Independent Contractor (QIC) Third Level of Appeal: Hearing by an Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals Fourth Level of Appeal: Review by the Medicare Appeals Council Fifth Level of Appeal: Judicial Review in Federal District Court OMHA is responsible for Level 3 claims appeals. The entry point of the appeals process depends on the part of the Medicare program that covers the disputed benefit or whether the beneficiary is enrolled in a Medicare Advantage plan. For more information on the different entry points based on Medicare Part, see Appeals Process by Medicare Type. There are five levels in the Medicare claims appeal process. The appeals process begins at Level 1. Level 1: Your Health Plan. If you disagree with a Medicare coverage decision, you may request your health plan to redetermine your claim. Level 2: An Independent Organization. If you disagree with the decision in Level 1, you may request a reconsideration by an independent organization. Level 3: Office of Medicare Hearings and Appeals (OMHA). If you disagree with the Level 2 decision, you may request that OMHA review your claim through an Administrative Law Judge. Level 4: The Medicare Appeals Council. If you disagree with the Administrative Law Judge's decision, you may request the Medicare Appeals Council review the decision. Level 5: Federal Court. If you disagree with the Medicare Appeals Council decision, you may seek a review of your claim in Federal District Court.
Types of Adjudication: 
Type A
Resources & Articles:
Verified by Agency: 
Is this a Major Adjudication: