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DAB Medicare Appeals Council Frequently Asked Questions

What is the purpose of these Frequently Asked Questions?

The answers to these frequently asked questions are meant to offer practical information for the convenience of parties who have cases before the Medicare Appeals Council, attorneys who represent such parties and others who have an interest in how the appeals process works. However, please be aware that this information does not override anything in the regulations that govern cases before the Medicare Appeals Council. Ultimately, parties and their attorneys are responsible for making their own determinations about how best to proceed.

What are the Medicare Appeals Council (MAC) and the Medicare Operations Division (MOD)?

The Medicare Operations Division (MOD) provides staff support to the Administrative Appeals Judges (AAJs) on the Medicare Appeals Council (MAC). The MAC provides the final administrative review of claims for entitlement to Medicare and individual claims for Medicare coverage and payment filed by beneficiaries or health care providers and suppliers. SSA makes the initial determination on claims for entitlement to Medicare. CMS contractors, including Medicare + Choice organizations, make initial determinations on individual claims for Medicare coverage and payment. On appeal, SSA ALJs provide a hearing. If dissatisfied with an ALJ hearing decision or dismissal, beneficiaries, health care providers and suppliers, or Medicare + Choice organizations may request MAC review or the MAC may undertake review at its discretion. The MAC may deny a request for review, or undertake review and issue a decision or dismissal or remand to an ALJ for further action. MAC decisions may be appealed to federal court if the amount in controversy requirements are met.

How can I find out what procedures apply?

DAB Medicare Appeals Council Regulations

Where do I file a Request for Review?

While you may file a request for review with your Medicare contractor, at a local Social Security office, or at certain other U.S. Government offices, we can consider the request for review more quickly if you send it directly to:

Department of Health and Human Services
Departmental Appeals Board, MS 6127
Medicare Appeals Council
330 Independence Avenue, SW, Room G-644
Washington DC 20201

You may also fax a request for review to (202) 565-0227.

Please do not send your appeal to the Appeals Council of the Social Security Administration (SSA) in Falls Church, Virginia. This will delay action on your case.

Other correspondence and inquiries concerning your appeal should be directed to the DAB MOD at the above address. You may call staff in the MOD at (202) 565-0100.

How do I file a Request for Review?

You must file a request for review in writing, either on a completed DAB Request for Review Form DAB-520, or in a letter to the MAC at the above address.

What should I include in the Request for Review?

Your request for review should include certain case identifying information, such as the:

  • beneficiary's name;

  • name of the health services provider;

  • date and type of service;

  • Medicare contractor or managed care organization that issued the initial determination in your case;
  • Health Insurance Claim Number (HICN);
  • SSA Docket Number (if any); and

  • date of the Administrative Law Judge (ALJ) decision or dismissal.

Form DAB-520

Your request for review should clearly state why you disagree with the ALJ decision or dismissal. You should include any supporting evidence or documentation, if it is not already part of the ALJ record.

You should attach a copy of the ALJ decision or dismissal order. This will decrease processing time.

When must I file a Request for Review?

You must file a request for review within 60 days after the date you receive notice of the ALJ decision or dismissal. See 20 CFR 404.968. We presume you received the notice 5 days after the date on the notice, unless you demonstrate that you did not receive the notice within the 5 day period. See 20 CFR 404.901

If you file a request for review late (more than 65 days after the date on the notice of ALJ decision or dismissal), you should explain why you had good cause for late filing. See 20 CFR 404.911 and 20 CFR 404.968 . The staff of the MOD reviews all requests for review for timeliness.

If you mail a request for review, we will use the date of the postmark as the date of filing. If you file at another office, we will use the date that office acknowledges receiving the request as the date of filing.

Should I send a copy of the Request for Review to anyone else?

When a request for review involves the obligations of a Medicare managed care organization, such as an HMO or Medicare + Choice organization, to furnish or pay for particular items or services:

If the beneficiary files the request for review, then the beneficiary should send a copy to the managed care organization.

If the managed care organization files the request for review, then the managed care organization should send a copy to the beneficiary.

Also, the request for review should indicate whether the services have already been furnished, or whether the appeal concerns items or services that the managed care organization has not yet paid for or supplied.

Similarly, if a request for review involves items or services furnished under "traditional" fee-for-service Medicare, you should send a copy to all parties to the ALJ decision or dismissal. The provider and beneficiary are usually both parties to the ALJ decision or dismissal.

What if I need more time to prepare something for the MAC?

Upon request, the MAC will give the appellant and all parties a reasonable opportunity to file additional briefs or other written statements about the facts and law relevant to the case. The request for review should state whether you would like additional time. A copy of each brief or statement should also be sent to each party. See 20 CFR 404.975. Only the MAC may grant an extension of time for additional submissions.

What happens after I file my Request for Review?

We will send you a letter acknowledging receipt of the request for review. Presently, our pending docket is quite large, and it may take some time until we can consider your case.

What if I need to talk to somebody there about my case?

You may call staff in the MOD at (202) 565-0100.

What will the MAC do with my Request for Review?

The MAC may deny or dismiss a request for review, or it may grant the request for review.

If the MAC grants the request for review, it may either issue a decision or send the case back ("remand") to an ALJ for further action.

The MAC may also grant review to dismiss a request for hearing.

If the MAC denies a request for review, the ALJ's decision stands as the final decision of HHS. If the MAC grants review and issues a decision, the MAC decision stands as the final decision of HHS.

The MAC will issue a written notice advising the parties of any action taken with respect to a request for review.

What is the MAC's Standard of Review?

The MAC will review a decision or dismissal if:

1) There appears to be an abuse of discretion by the ALJ;
2) There is an error of law;
3) The actions, findings or conclusions of the ALJ are not supported by substantial evidence; or
4) There is a broad policy or procedural issue that may affect the general public interest.
5) The regulations also provide that where new and material evidence is submitted with the request for review, the entire record will be evaluated and review will be granted where the MAC finds that the Administrative Law Judge's action, findings, or conclusion is contrary to the weight of the evidence currently of record.

See 20 CFR 404.970.

Can the MAC review a case on its own motion?

Anytime within 60 days after the date of an ALJ decision or dismissal, the MAC may decide on its own motion to review the ALJ's action. See 20 CFR 404.969.

The MAC may also reopen a final decision or dismissal under limited circumstances. See 20 CFR 404.987 and 20 CFR 404.988.

Does the MAC hold hearings?

The MAC conducts an appellate review of the ALJ record, and generally does not hold an evidentiary hearing. In limited circumstances, the MAC may hold oral argument in a case. See 20 CFR 404.976. If you request an oral argument, you must do so in writing and state your reasons.

How can I find MAC decisions?

MAC Decisions

Can I go to court after the MAC acts on my case?

You may have the right to court review. Our notice of decision or letter denying review of an ALJ decision will give general information about filing a court complaint. It is not appropriate, however, for the MAC to offer advice or assistance concerning whether, and how, an appellant may seek court review.

The right to court review of a final decision is provided for in cases arising under title XVIII of the Social Security Act if the amount in controversy is $1,000 or more (section 1869(b) of the Act (42 U.S.C. 1395ff(b)), or sections 1852(g)(5) or 1876(c)(5)(B) of the Act if a managed care organization HMO is involved (42 U.S.C. 1395mm(c)(5)(B))). See 42 CFR 405.730, 42 CFR 405.857, 42 CFR 417.636, and 42 CFR 422.612.

The right to court review is provided for in cases arising under title XI of the Act where the amount in controversy is $2,000 or more (section 1155 of the Act (42 U.S.C. 1320c-4)). See 42 CFR 478.46.

If you desire a court review and the amount in controversy requirement is met, you may commence a civil action by filing a complaint in the United States District Court for the judicial district in which you reside, or have your principal place of business, within sixty (60) days from the date of the receipt of the MAC's decision or letter denying review. We presume that you will receive the MAC action within five (5) days after the date shown on it unless a reasonable showing to the contrary is made.

What if I can't file my court complaint in time?

If you cannot file your complaint within 60 days, you may ask the MAC to extend the time in which you may begin a civil action. However, the Council will only extend the time if you provide a good reason for not meeting the deadline. Your reason(s) must be set forth clearly in your request. See 20 CFR 404.982.

Who is the defendant in a court complaint?

If a civil action is commenced, the complaint should name the Secretary of Health and Human Services as the defendant and should include the Health Insurance Claim Number (HICN) and/or SSA Docket Number, if any, shown on the decision. The Secretary must be served by sending a copy of the summons and complaint by registered or certified mail to the General Counsel, Department of Health and Human Services, 200 Independence Avenue, S.W., Washington, D.C. 20201. In addition, you must serve the United States Attorney for the district in which you file your complaint and the Attorney General of the United States. (See rules 4(c) and (i) of the Federal Rules of Civil Procedure and 45 CFR 4.1.)
45 CFR 4.1.

Medicare Appeals Council Regulations

Medicare Operations Division/Medicare Appeals Council

Last revised: February 25, 2004

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