Legal: Request reviews thoughtfully

Sunday, January 22, 2012

A. If you want to continue to pursue your appeal after an unfavorable ALJ decision, you can request review of that decision by the Medicare Appeals Council (MAC). The MAC, which is a part of the Departmental Appeals Board of the Department of Health and Human Services, is the next level of the Medicare appeals process after ALJ review. It is independent from the ALJs and conducts a "de novo" review, meaning it does not have to defer to the decisions issued in your appeal at previous levels.  

Any party to an appeal may request MAC review of an ALJ decision by submitting a timely request for review. However, the MAC will limit its review to the specific issues raised in your request. This makes your request for review one of the most important parts of your appeal. You may also request a copy of the case file and the ability to comment on that evidence, which provides another opportunity for argument in support of your appeal.  

Unlike at the ALJ level of appeal, you do not have the right to a hearing before the MAC. Instead you may request the opportunity to present oral argument, but oral argument is only granted in cases that the MAC feels raise important questions of law, policy or fact that cannot be decided solely on the written record.  

While regulation requires the MAC to issue a decision or take other action on most requests within 90 calendar days of receipt of the request for review, recent caseloads may lead to a wait time of up to a year or more for a decision. Requesting the case file or oral argument also extends the MAC's time frame for deciding your case. You do have the right to escalate your appeal to Federal court if the MAC fails to take action within the required time frame, but this can be a costly, time intensive step.