By recei Dispute/Reconsiderations: A disagreement between Insurance and a provider over the amount the provider was paid for the claim versus what the provider needed to be paid under Original Medicare. Reconsiderations represent your initial Appeal request for an investigation into a claim outcome. Provider may contact insurance via phone, website or mail within time frame to challenge the decision.
Note: Always call to insurance company (Humana, UHC, Aetna, Allied benefits, Cigna) get exact time frame for appeal filing for contracted or non-contracted provider.
- Sometime Insurance update their time limit to submit reconsideration.
- To Justify your point the provider’s team, need to submit following document:
- The reasons of disagreement of the decision made.
- The Explanation of Benefits (EOB) statement along with the original claim form either CMS-1500 or UB-04 form for reference.
- Supporting documents like remittance advice from a Medicare; office notes; medical records, etc.
Appeal: If you are not satisfied with the determination of the reconsideration request, you can request a formal appeal. Although there are many payors which accept two to maximum three level of appeals but for Medicare it can go up to 5 levels.
- Appeals letter: Always contact insurance company as many insurances have their Standard appeal letters which are available on their websites. When filing standard appeals it is important to submit the documents which have been requested by the insurance company.
- Always ask for appeal filing limit and note down the mailing address, fax, or provider portal carefully as it may delay the task of appeal filing and cause denial of Timely filing limit.
- Always take action carefully while appealing as there are limit on how many times appeal can be filed.
Medicare Appeal
The five levels of Medicare Appeals are:
Level 1: Redetermination (no minimum monetary limit) –Time limit is 120 days from the date of receipt of the initial determination letter.
Level 2: Reconsideration (no minimum) – Time limit is 180 days from the date of receipt of the Medicare Redetermination letter.
Level 3: Administrative Law Judge (ALJ) (minimum amount is $190 for 2025) – Time limit is 60 days from the date of receipt of the reconsideration letter along with you need to submit why you are disagreeing over the previous decisions.
Level 4: Medicare Appeals Council (MAC) (no monetary minimum) – Time limit is 60 days from the date of receipt of the Administrative Law Judge decision.
Level 5: Federal Court of Appeals (minimum amount is $1900 for 2025) – Time limit is 60 days of the Medicare Appeals Council determination.
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