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The document is a form for submitting a Medicare reconsideration request, allowing beneficiaries or their representatives to appeal a redetermination decision regarding Medicare claims. It includes sections for personal information, details about the service or item being appealed, reasons for disagreement, and evidence submission.

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How does a provider appeal a Medicare claim?

Fill out a "Redetermination Request Form [PDF, 100 KB]" and send it to the company that handles claims for Medicare. Their address is listed in the "Appeals Information" section of the MSN. Or, send a written request to company that handles claims for Medicare to the address on the MSN.

What is a reconsideration review?

A. A reconsideration involves a thorough, independent review of all evidence from the initial determination and any new evidence the claimant or another individual submits in connection with the request for reconsideration.

What is a QIC reconsideration?

A reconsideration is an independent review of the administrative record, including the initial determination and redetermination, by a Qualified Independent Contractor (QIC).

How long does Medicare have to respond to an appeal for reconsideration?

How long your plan has to respond to your request depends on the type of request: Expedited (fast) request\u201472 hours. Standard service request\u201430 days.

What is the first step in the Medicare appeals process?

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.

What are the five steps in the Medicare appeals process?

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.

What does QIC stand for in Medicare?

Appeals Level 2: Qualified Independent Contractor (QIC) Reconsideration | Medicare. Here's how you know. Official websites use .gov. A .gov website belongs to an official government organization in the United States.

What is the third level of appeal?

Appeals Level 3: Decision by the Office of Medicare Hearings and Appeals (OMHA) You may request a decision by OMHA, based on a hearing before an Administrative Law Judge (ALJ) or, in certain circumstances, a review of the appeal record by an ALJ or attorney adjudicator.

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