Full Definition

Medicare coverage appeals follow a 5-level process: Level 1 — Redetermination by the Medicare Administrative Contractor (MAC); Level 2 — Reconsideration by a Qualified Independent Contractor (QIC); Level 3 — Administrative Law Judge (ALJ) hearing; Level 4 — Medicare Appeals Council review; Level 5 — Federal district court review.

For urgent situations — such as hospital discharge or SNF coverage ending — expedited appeals are available with faster response times. For hospital discharge, the BFCC-QIO (Livanta in Texas) handles expedited discharge appeals.

For SNF coverage ending, a beneficiary who disagrees with the SNF’s determination that Medicare no longer covers their care can request a BFCC-QIO review. The SNF must provide a written notice (Notice of Medicare Non-Coverage) at least 2 days before coverage ends, which includes appeal instructions. Filing an appeal before the coverage end date prevents being billed while the appeal is pending.