Understanding the 'Amount in Controversy' for Medicare Appeals
The Medicare appeals process can be a long journey, but not all denied claims are eligible to proceed through every level. For an appeal to reach the higher, more formal levels of review—specifically a hearing with an Administrative Law Judge (ALJ) or a review in Federal District Court—it must meet a minimum financial threshold known as the "Amount in Controversy".
Understanding this requirement is crucial for determining if your appeal can move forward after the initial administrative reviews.
What is the Amount in Controversy?
The Amount in Controversy is the minimum dollar value that Medicare would have likely paid for the denied service or item in dispute. This amount is set annually by the Centers for Medicare & Medicaid Services (CMS), and it is the same for appeals across all parts of Medicare.
When Does it Apply?
The Amount in Controversy requirement applies to two levels of the appeals process:
Level 3: Hearing Before an Administrative Law Judge (ALJ): Your Level 2 denial notice will state the specific Amount in Controversy amount that you must meet to request an ALJ hearing.
Level 5: Judicial Review in U.S. District Court: This is the highest level of appeal and requires a separate, higher Amount in Controversy threshold to be met before you can file a lawsuit in federal court.
How to Calculate the Amount in Controversy
To get a general idea of the Amount in Controversy for your claim, you can look at the difference between what the service or item cost and what Medicare (or your plan) has already paid or agreed to pay. The remaining unpaid amount is generally considered the Amount in Controversy.
Aggregating Multiple Claims
If a single denied claim doesn't meet the required amount, you may be able to aggregate (combine) multiple claims that were denied at the Level 2 stage to reach the threshold. To do this, your request must specify all the claims you are combining and explain why they involve the same individual or common issues.