APMA News - September/October 2020 - 19

by CMS for review and an independent decision. If the physician disagrees with the IRE's decision, and the amount at
issue meets a specified dollar threshold, the physician may
appeal the case to an administrative law judge (ALJ) on behalf
of the member.
In addition, any physician may make a written or oral request for an expedited pre-service appeal if they believe that
making a decision under the standard timeframe could seriously jeopardize the life or health of the member or the member's ability to regain maximum function. Where requested
by a physician, the plan must grant the request to expedite
the appeal. Expedited appeals must be requested within 60
days of the date of the adverse decision. The health plan has
up to 72 hours to make a decision but must make it as expeditiously as the member's health requires. If the plan upholds
its previous denial, it must forward the case file to the IRE for
review and decision. If the physician disagrees with the IRE's
decision, and the amount at issue meets a specified dollar
threshold, the physician may appeal the case to an ALJ.

Non-Contracted Providers
The appeal process for non-contracted providers is the
member appeal process set forth in MA law and policy. The
applicable procedures vary depending on whether the issue
being appealed is a pre-service denial, a payment denial, or
a situation in which the plan made payment, but the physician believes the amount is less than original Medicare
would have paid.
The process for appealing pre-service denials is the same
as set forth above for contracting providers. Like contracted
providers, a non-contracted provider who is providing
treatment to a member may request an appeal on the member's behalf.
If an MA organization denies a request for payment from
a non-contracted provider, the organization must notify the
provider of the specific reason for the denial and provide a
description of the appeals process. To appeal a denial of
payment, a non-contracted provider must sign a waiver of
liability specifying that the provider will not bill the member regardless of the outcome of the appeal. A provider who
follows this procedure then stands in the shoes of the member for purposes of using the member appeal process. A
provider has 60 days after receiving the organization determination to request an appeal. The MA organization has 60
days to make a decision on the claims appeal. If it upholds
its previous denial or fails to provide a decision in 60 days,
it must automatically forward the case file to an IRE for review and an independent decision. If the physician disagrees with the IRE's decision, and the amount at issue
meets a specified dollar threshold, the physician may appeal
the case to an ALJ.

Useful Resources
The MA regulations regarding appeals are set forth at 42 CFR
Part 422 Subpart M.

The process is further explained in detailed CMS
guidance, which is available at https://www.cms.gov/
Medicare/Appeals-and-Grievances/MMCAG/Downloads/
Parts-C-and-D-Enrollee-Grievances-OrganizationCoverage-Determinations-and-Appeals-Guidance.pdf.
Endnotes
There is an exception from the requirement to follow LCDs
that allows plans that include multiple Medicare Administrative Contractors (MACs) within their service area to adopt a
uniform Medicare coverage policy with CMS's approval. Plans
doing so must make information on the selected LCDs available to providers and members.
1

As previously noted, PPOs may not require non-contracting
providers to obtain prior authorization, furnish prior notification, or obtain a referral as a condition of coverage. However, like all MA plans, they may do a retrospective review of
medical necessity.

The health plan may extend this time period by 14 days if
the member requests the extension; the extension is justified
and in the member's interest due to the need for additional
medical evidence from a non-contract provider that may
change an MA organization's decision to deny an item or service; or the extension is justified due to extraordinary, exigent, or other non-routine circumstances and is in the member's interest.
3

For 2020, the amount in controversy threshold is $170 for
ALJ hearings. Additional levels of appeals available to the provider after the ALJ include (in order) appeals to the Medicare
Appeals Council and Federal Court. The amount in controversy threshold is $1,670 for federal court for 2020.

APMA News September/October 2020

https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Downloads/Parts-C-and-D-Enrollee-Grievances-Organization-Coverage-Determinations-and-Appeals-Guidance.pdf https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Downloads/Parts-C-and-D-Enrollee-Grievances-Organization-Coverage-Determinations-and-Appeals-Guidance.pdf https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Downloads/Parts-C-and-D-Enrollee-Grievances-Organization-Coverage-Determinations-and-Appeals-Guidance.pdf https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Downloads/Parts-C-and-D-Enrollee-Grievances-Organization-Coverage-Determinations-and-Appeals-Guidance.pdf

APMA News - September/October 2020

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