Q&A: Understanding fourth-level Medicare appeals

Q: What's the process for a fourth level Medicare appeal?

A: Upon receipt of an unfavorable decision by the ALJ, the hospital may request a hearing before the Medicare Appeals Council. The hospital has 60 days from the date of receipt of the ALJ decision to file a request for a Medicare Appeals Council hearing. The hearing request must be requested in writing by either of the following methods:

• Filling out the form DAB-101. This form can be downloaded from the CMS website (see Figure 3.4).
• Making a written request. If this method is chosen, the written request must contain the following information:
  • Beneficiary name
  • Medicare HIC number
  • Beneficiary address
  • Date of service being appealed
  • The date of the ALJ’s decision
  • Name and signature of the person submitting the redetermination

A Medicare Appeals Council hearing does not have to meet a minimum monetary threshold.

The hospital must submit all ALJ hearing request to the following address:

Department of Health and Human Services
Departmental Appeals Board
Medicare Appeals Council, MS 6127
Cohen Building Room G-644
330 Independence Ave., S.W.
Washington, D.C. 20201

For more information, see The Contemporary Guide to Patient Financial Services.