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Medicare Appeals Level 4: Review by Medicare Appeals Council

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

To request that the Medicare Appeals Council (Appeals Council) review the ALJ’s decision in your case, follow the directions in the ALJ’s hearing decision you got in level 3. You must send your request to the address listed in the ALJ’s hearing decision. You can file a request for Appeals Council review in 1 of 2 ways:
1. Fill out a “Request for Review of an Administrative Law Judge (ALJ) Medicare Decision/Dismissal” form
2. Submit a written request to the Appeals Council that includes:
• Your name and Medicare number. If you’ve appointed a representative, include the name of your representative.
• The specific item(s) and/or service(s) and specific date(s) of service you’re appealing. See your MSN or your ALJ hearing decision for this information.
• A statement identifying the parts of the ALJ’s decision with which you disagree and an explanation of why you disagree.
• The date of the ALJ decision.
• Your signature. If you’ve appointed a representative, include the signature of your representative.
• If you’re requesting that your case be moved from the ALJ to the Appeals Council because the ALJ hasn’t issued a timely decision, include the hearing office in which the request for hearing is pending.
3. If the Appeals Council doesn’t issue a timely decision, you can ask the Appeals Council to move your case to the next level of appeal.
4. If you disagree with the Appeals Council’s decision in level 4, you have 60 days after you get the decision to request judicial review by a federal district court.

Appeals Level 5: Federal district court judicial review
To get a judicial review in federal district court, the amount of your case must meet a minimum dollar amount. For 2017, the minimum dollar amount is $1,560. You may be able to combine claims to meet this dollar amount. Follow the directions in the MAC’s decision letter you got in level 4 to file a complaint.

Making a Special Needs Plan coverage decision appeal
Your Medicare Special Needs Plan (SNP) must tell you in writing how to appeal. After you file an appeal, the plan will review its original decision. If your plan doesn’t decide in your favor, the appeal is reviewed by an independent organization that works for Medicare, not for the plan.

Can someone file an appeal for me?
Contact your State Health Insurance Assistance Program (SHIP) if you need help filing an appeal.
Or, you can appoint a representative to help you. Your representative can be a family member, friend, advocate, attorney, doctor or someone else who will act on your behalf.
(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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