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The Medicare Operations Division/The Medicare Appeals Council

Medicare Operations Division - The Medicare Operations Division 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/suppliers.

The Social Security Administration (SSA) makes the initial determination on a claim for entitlement to Medicare. A contractor of the Centers for Medicare and Medicaid Services (CMS), including a Medicare+Choice organization, makes an initial determination on an individual claim for Medicare coverage and payment. On appeal, a SSA Administrative Law Judge (ALJ) provides a hearing. If dissatisfied with an ALJ decision or dismissal, a Medicare beneficiary, health care provider/supplier, or Medicare+Choice organization may request MAC review. The MAC may also undertake review of an ALJ decision at its discretion.

The MAC may deny a request for review, or undertake review and issue a decision, dismissal, or remand to an ALJ for further action. A MAC decision may be appealed to federal court if certain "amount in controversy" requirements are met.

Medicare Appeals Council Regulations

DAB Medicare Appeals Council Frequently Asked Questions

Last revised: November 20, 2003

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