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Patient Name: ______________________________
HCIN# ______________
Medicare Claim # ____________________ (13 digits)
Service date: ________________
Amount in question: _______________
Date of original claim denial/partial or underpayment: _____________________
- Review: Must request within 6 months of initial claim denial. Can be telephone (quickest) or in writing (use HCFA 1964).
Requested: ____________
Telephone Review date & results: ____________________
Written review on HCFA 1964: Date _______ Results_____
- Fair Hearing: Must request within 6 months of Review denial and (3 types) must be at least $100.00 in controversy. (Can combine multiple claims & different patients to reach $100)
Type & Date requested: _______________________________________
On-the-record Fair Hearing: Simply state the arguments. No testimony is presented either by telephone or in person.
Telephone Fair Hearing: Testimony is presented via telephone (quickest).
In-Person Fair Hearing: In person, oral testimony, must be done in the city the provider provided the service.
Results: ___________________________________________________
- Administrative Law Judge Hearing: Must be within 60 days/$500. This can take anywhere from 1 to 3 years.
Requested: ___________
Results: ___________________
- Appeals Council Review: Must be requested within 60 days of ALJ denial. No specific time limit set on when Appeals Council must act.
- Federal District Court: You file a lawsuit. Last resort, expensive, must be $1000.00 in controversy.
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