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Appeal Level 2 and Level 3 If you have Original Medicare

Sudhir Mathuria  Licensed  Professional Health Life 360 6776 Southwest Freeway, Suite # 178 Houston TX 77074 713-771-2900 www.MyMedicarePlanning.com

Sudhir Mathuria
Licensed Professional
Health Life 360
6776 Southwest Freeway, Suite # 178
Houston TX 77074
713-771-2900
www.MyMedicarePlanning.com

Appeals Level 2:
A QIC is an independent contractor that didn’t take part in the level 1 decision. The QIC will review your request for a reconsideration and make a decision.
The redetermination notice you got in level 1 has directions for you to file a request for reconsideration.
There are 2 ways to submit a reconsideration request.
1. Fill out a “Medicare Reconsideration Request Form.”
2. Submit a written request to the QIC that includes:
• Your name and Medicare number.
• The specific item(s) or service(s) for which you’re requesting a reconsideration and the specific date(s) of service. See your redetermination notice for this information.
• The name of the company that made the redetermination (the company that handles claims for Medicare). See the MSN or the redetermination notice for this information.
• An explanation of why you disagree with the redetermination decision.
• Your signature. If you’ve appointed a representative, include the name and signature of your representative.
In most cases, the QIC will send you a written response called a “Medicare Reconsideration Notice” about 60 days after the QIC gets your appeal request. If the QIC doesn’t issue a timely decision, you may ask the QIC to move your case to the next level of appeal.
If you disagree with the reconsideration decision in level 2, you have 60 days after you get the “Medicare Reconsideration Notice” to request an Administrative Law Judge (ALJ) hearing.
Appeals Level 3:
Hearing before Administrative Law Judge
A hearing before an Administrative Law Judge (ALJ) allows you to present your appeal to a new person. The ALJ will review the facts of your appeal independently and listen to your testimony before making a new and impartial decision. An ALJ hearing is usually held by phone or video-teleconference, or in some cases, in person. You can also ask the ALJ to make a decision without a hearing. The ALJ may also issue a decision without holding a hearing if evidence in the hearing record supports a decision that’s fully in your favor.
To get an ALJ hearing, the amount of your case must meet a minimum dollar amount. For 2017, the required minimum amount is $160. The ALJ will decide if your case meets the minimum dollar amount. You may be able to combine claims to meet the minimum dollar amount.
If you have Original Medicare, follow the directions on the “Medicare Reconsideration Notice” you got from the QIC in level 2 to request a hearing before an ALJ. You must send your request to the appropriate Office of Medicare Hearings and Appeals (OMHA) Central Operations. The address is listed in the QIC’s reconsideration notice.
If you have Original Medicare, a Medicare Advantage plan, other Medicare health plan, or a Medicare Prescription Drug Plan, you can request a hearing in one of these ways:
1. Fill out a “Request for Medicare Hearing by an Administrative Law Judge” form.
2. Submit a written request to the OMHA office that will handle your ALJ hearing that includes:
• Your name, address, and Medicare number. If you’ve appointed a representative, include your representative’s name and address.
• The appeal number included on the QIC reconsideration notice, if any.
• The dates of service for the items or services you’re appealing. See your MSN or reconsideration notice for this information.
• An explanation of why you disagree with the reconsideration decision being appealed.
• Any information that may help your case. If you can’t include this information with your request, include a statement explaining what you plan to submit and when you’ll submit it.
(To Be Continued)
To choose right Medicare Supplement plan, Medicare Advantage Plan or Medicare Prescription Drug plan, contact Sudhir Mathuria @ 713-771-2900.


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