Second Level of Appeal: Reconsideration by a Qualified Independent Contractor

Any party to the redetermination that is dissatisfied with the decision may request a reconsideration. A reconsideration is an independent review of the administrative record, including the initial determination and redetermination, by a Qualified Independent Contractor (QIC).

Requesting a Reconsideration

The appellant (the individual filing the appeal) has 180 days from the date of receipt of the redetermination decision to file a reconsideration request. The redetermination decision can be communicated through a Medicare Redetermination Notice (MRN), a Medicare Summary Notice (MSN), or a Remittance Advice (RA). The redetermination decision is presumed to be received 5 days after the date on the notice unless there is evidence to the contrary. 

A reconsideration must be requested in writing. Instructions for filing a reconsideration request are on the MRN, and can also be found on the website of the Medicare Administrative Contractor (MAC) that issued the redetermination. A list of MAC websites and contact information can be found at: /Medicare/Medicare-Contracting/Medicare-Administrative-Contractors/Who-are-the-MACs#MapsandLists 

A reconsideration request can be filed using either:

1. The form CMS-20033 (available in “Downloads" below), or
2. Send a written request containing all of the following information:
   • Beneficiary's name
   • Beneficiary's Medicare number
   • Specific service(s) and item(s) for which the reconsideration is requested, and the specific date(s) of service
   • Name of the party or the authorized or appointed representative of the party
   • Name of the contractor that made the redetermination
   • Any missing documentation identified in the notice of redetermination

The request should clearly explain why the appellant disagrees with the redetermination, and be accompanied by any evidence or allegations of fact or law related to the issue(s) in dispute. A copy of the MRN or RA, and any other relevant documentation, should be sent with the reconsideration request to the appropriate QIC. A minimum monetary threshold is not required to request a reconsideration.

Documentation that is submitted after the reconsideration request has been filed may result in an extension of the timeframe a QIC has to complete its decision. This does not apply to timely submission of documentation requested by the QIC. It is not necessary to resubmit information that was already submitted to the MAC. Any documentation not submitted at the reconsideration level may be excluded from consideration at subsequent levels of appeal unless good cause is shown for not submitting the documentation previously.

QIC Review of a Dismissal of a Redetermination Request

If a MAC has dismissed a redetermination request, any party to the redetermination has the right to appeal a dismissal of a redetermination request to a QIC if they believe the dismissal is incorrect. The request for review must be filed with the QIC within 60 days after the date of receipt of the dismissal. When the QIC performs its review of the dismissal, it will only decide on whether or not the dismissal was correct. If it determines that the MAC incorrectly dismissed the redetermination, it will vacate the dismissal and remand the case to the MAC for a redetermination. See “First Level of Appeal” webpage (left navigation bar) for more information on MAC dismissals.

NOTE: A QIC’s action after review of a MAC’s dismissal of a redetermination request is binding and not subject to any further review or appeal.

Dismissal of a Reconsideration Request

A QIC may dismiss a reconsideration request in the following instances:

1. If the party (or appointed representative) requests to withdraw the appeal; or
2. If there are certain defects, such as
   1. The party fails to file the request within the appropriate timeframe and did not show (or the QIC did not accept) good cause for late filing
   2. The representative is not appointed properly
   3. The requestor is not a proper party

Detailed information on QIC dismissals can be found at 42 CFR 405.972.

Parties to a QIC's dismissal of a request for reconsideration have 2 options if they disagree with the dismissal:

1. Request review of the dismissal by an Administrative Law Judge (ALJ,) or attorney adjudicator at the Office of Medicare Hearings and Appeals (OMHA)
2. Request that the QIC vacate the dismissal

Original Medicare (Fee-For-Service) Qualified Independent Contractors

The following is a list of the QICs and the jurisdictions that they serve:

Maps of the QIC jurisdictions, mailing addresses and website information for all QICs are available in “Downloads” under "QIC Maps."

Electronic Submission of Reconsideration Request

QICs have established alternative communication mediums for CMS stakeholders to submit reconsideration requests and related documentation to the QICs. The websites for the respective QIC jurisdictions contain instructions to stakeholders for electronic (e.g., fax or portal) submission of reconsideration requests or documentation. Guidance regarding the options for submitting reconsiderations and related documentation is also summarized by QIC jurisdiction in the table below.

Note: implementation of these alternative mechanisms does not preclude CMS stakeholders from ongoing submission of 2^nd level appeals via hard copy mail.

Another ongoing, alternative method to submit electronic 2^nd level Medicare FFS Part A and Home Health and Hospice (HH+H) claim appeal reconsiderations, is through your Medicare Administrative Contractor (MAC) portal. The table below summarizes MACs that currently support electronic 2^nd level Part A and HH+H reconsideration intake automatically routed to the QIC.

QIC Telephone Discussion and Reopening Process Demonstration

On January 1, 2016, the Centers for Medicaid & Medicaid Services (CMS) launched the Telephone Discussion and Reopening Process Demonstration (the Demonstration) with Durable Medical Equipment (DME) suppliers that submit Medicare fee-for-service claims. The Demonstration allowed selected suppliers and providers to participate in a telephone discussion at the Qualified Independent Contractor (QIC) level and have claims currently pending at the Office of Medicare Hearings and Appeals (OMHA) remanded to and reopened by the QIC and resolved. On May 1, 2019, CMS expanded Demonstration activities to the Part A East QIC Jurisdiction to include certain Part A and home health and hospice appeals.

The six-year Demonstration effort ended on December 31, 2021. See the links below in the “Downloads” section for the final Medicare Appeals Demonstration Fact Sheet, and Demonstration Findings at a Glance.