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The first level of an appeal for Original Medicare is called a redetermination. A redetermination is performed by the same contractor that processed your Medicare claim. However, the individual that performs the appeal is not the same individual that processed your claim.
The appeals process has 5 levels. If you disagree with the decision made at any level of the process, you can generally go to the next level. At each level, you'll get instructions in the decision letter on how to move to the next level of appeal.
If you have a question, concern or complaint, please call our Customer Service department at 888.975. 8102 (TTY users call 711). If you are not happy with the answers that our representative has provided, you or someone acting on your behalf can send us a formal complaint, also called a grievance.
For the contracts we reviewed for 2014-16, beneficiaries and providers filed about 607,000 appeals for which denials were fully overturned and 42,000 appeals for which denials were partially overturned at the first level of appeal. This represents a 75 percent success rate (see exhibit 2).
When a claim is denied because the information submitted was incorrect, often the claim can be reopened using a Clerical Error Reopening (CER). CERs can be used to fix errors resulting from human or mechanical errors on the part of the party or the contractor.

People also ask

Appeal the claims decision. The first level of an appeal for Original Medicare is called a redetermination. A redetermination is performed by the same contractor that processed your Medicare claim. However, the individual that performs the appeal is not the same individual that processed your claim.
The Social Security Act (the Act) establishes five levels to the Medicare appeals process: redetermination, reconsideration, Administrative Law Judge hearing, Medicare Appeals Council review, and judicial review in U.S. District Court. At the first level of the appeal process, the MAC processes the redetermination.
The Social Security Act (the Act) establishes five levels to the Medicare appeals process: redetermination, reconsideration, Administrative Law Judge hearing, Medicare Appeals Council review, and judicial review in U.S. District Court. At the first level of the appeal process, the MAC processes the redetermination.
There are 5 levels of appeals available to you: Redetermination. Reconsideration. Administrative Law Judge (ALJ)
If you disagree with a Medicare coverage or payment decision, you can appeal the decision. Your MSN contains information about your appeal rights. If you decide to appeal, ask your doctor, other health care provider, or supplier for any information that may help your case.

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