Appeals
You can appeal our original decision concerning your case. Discover how here.
You may ask us to review our initial determination, even if only part of our decision is not what you requested. An appeal to the plan about Part C medical care or services is also called plan “reconsideration”. When we receive your request to review the initial determination, we give the request to people at our organization who were not involved in making the initial determination. This helps ensure that we will give your request a fresh look.
Who may file your appeal of the initial determination?
If you are appealing an initial decision about Part C medical care or services, the rules about who may file an appeal are the same as the rules about who may ask for an organization determination. Follow the instructions under “Who may ask for an initial determination?”. However, providers who do not have a contract with the Plan may also appeal a payment decision as long as the provider signs a “waiver of payment” statement saying it will not ask you to pay for the Part C medical care or service under review, regardless of the outcome of the appeal.
How soon must you file your appeal?
You must file the appeal request within 60 calendar days from the date included on the notice of our initial determination. We may give you more time if you have a good reason for missing the deadline.
How to file your appeal?
- Asking for a standard appeal – To ask for a standard appeal about a Part C medical care or service, you should send a written and signed appeal request by mail or fax.
- Asking for a fast appeal – If you are appealing a decision we made about giving you a Part C medical care or service that you have not received yet, you and/or your doctor will need to decide if you need a fast appeal. The rules about asking for a fast appeal are the same as the rules about asking for a fast initial determination. You, your doctor, or your representative may ask us for a fast appeal by calling or sending a letter by fax or mail.
Be sure to ask for a “fast” or “expedited” review. Remember, if your doctor provides a written or oral supporting statement explaining that you need the “fast” appeal, we will automatically give you a “fast” appeal. If you ask for a “fast” decision without support from a doctor, we will decide if your health requires a “fast” decision. If we decide that your medical condition does not meet the requirements for a “fast” decision, we will send you a letter informing you that if you get a doctor’s support for a “fast” review, we will automatically give you a fast decision. The letter will also tell you how to file a “fast grievance”. You have the right to file a “fast grievance” if you disagree with our decision to deny your request for a “fast” review (for more information about “fast grievances”, see your Evidence of Coverage). If we deny your request for a “fast” appeal, we will give you a “standard” appeal.
Please note that even when the initial coverage determination and the appeals process is the same, the appeals are managed by our Appeals and Grievances Department.
Getting information to support your appeal
We must gather all the information we need to make a decision about your appeal. If we need your assistance in gathering this information, we will contact you, your representative or your physician. You have the right to obtain and include additional information as part of your appeal. For example, you may already have documents related to your request, or you may want to get your doctor’s records or opinion to help support your request. You may need to give the doctor a written request to get information.
You may give us your additional information to support your appeal by:
- mail and send it to:
MMM of Florida
Appeals and Grievances
P.O. Box 260430
Miami, FL 33126 - Telephone: 1-844-212-9858 (Toll free), 1-833-523-2620 (TTY), Monday to Friday, 8:00 a.m. to 8:00 p.m.
- Fax: 1-833-523-2626
You also have the right to ask us for a copy of information regarding your appeal.
How soon must we decide on your appeal?
- For a decision about payment for Part C medical care or services you already received.
After we receive your appeal request, we have 60 days to decide. If we do not decide within 60 days, your appeal automatically goes to Appeal Level 2.
- For a standard decision about Part C medical care or services you have not yet received.
After we receive your appeal, we have 30 days to decide, but will decide sooner if your health condition requires. However, if you ask for more time, or if we find that helpful information is missing, we can take up to 14 more days to make our decision. If we do not tell you our decision within 30 days (or by the end of the extended time period), your request will automatically go to Appeal Level 2.
- For a fast decision about Part C medical care or services you have not yet received.
After we receive your appeal, we have 72 hours to decide, but will decide sooner if your health condition requires. However, if you ask for more time, or if we find that helpful information is missing, we can take up to 14 more days to make our decision. If we do not decide within 72 hours (or by the end of the extended time period), your request will automatically go to Appeal Level 2.
What happens if we decide completely in your favor?
- For a decision about payment for Part C medical care or services you already received.
We must pay within 60 days of receiving your appeal request.
- For a standard decision about Part C medical care or services you have not yet received.
We must authorize or provide your requested care within 30 days of receiving your appeal request. If we extended the time needed to decide your appeal, we will authorize or provide your requested care before the extended time period expires.
- For a fast decision about Part C medical care or services you have not yet received.
We must authorize or provide your requested care within 72 hours of receiving your appeal request. If we extended the time needed to decide your appeal, we will authorize or provide your requested care before the extended time period expires.
At the second level of appeal, your appeal is reviewed by an outside, Independent Review Entity (IRE) that has a contract with the Centers for Medicare & Medicaid Services (CMS). The IRE has no connection to us. You have the right to ask us for a copy of your case file that we sent to this entity.
How to file your appeal?
If you asked for Part C medical care or services, or payment for Part C medical care or services, and we did not rule completely in your favor at Appeal Level 1, your appeal is automatically sent to the IRE.
How soon must the IRE decide?
The IRE has the same amount of time to make its decision as the plan had at Appeal Level 1.
What happens if the IRE decides completely in your favor?
The IRE will tell you in writing about its decision and the reasons for it.
- For a decision about payment for Part C medical care or services you already received.
We must pay within 30 days after we receive notice reversing our decision.
- For a standard decision about Part C medical care or services you have not yet received.
We must authorize your requested Part C medical care or service within 72 hours, or provide it to you within 14 days after we receive notice reversing our decision.
- For a fast decision about Part C medical care or services.
We must authorize or provide your requested Part C medical care or services within 72 hours after we receive notice reversing our decision.
If the IRE does not rule completely in your favor, you or your representative may ask for a review by an Administrative Law Judge (ALJ) if the dollar value of the Part C medical care or service you asked for meets the minimum requirement provided in the IRE’s decision. During the ALJ review, you may present evidence, review the record (by either receiving a copy of the file or accessing the file in person when feasible), and be represented by counsel.
How to file your appeal?
The request must be filed with an ALJ within 60 calendar days of the date you were notified of the decision made by the IRE (Appeal Level 2). The ALJ may give you more time if you have a good reason for missing the deadline. The decision you receive from the IRE will tell you how to file this appeal, including who can file it.
The ALJ will not review your appeal if the dollar value of the requested Part C medical care or service does not meet the minimum requirement specified in the IRE’s decision. If the dollar value is less than the minimum requirement, you may not appeal any further.
How soon will the Judge make a decision?
The ALJ will hear your case, weigh all of the evidence, and make a decision as soon as possible.
If the Judge decides in your favor:
See the section “Favorable Decisions by the ALJ, MAC, or a Federal Court Judge” below for information about what we must do if our decision denying what you asked for is reversed by an ALJ.
If the ALJ does not rule completely in your favor, you or your representative may ask for a review by the Medicare Appeals Council (MAC).
How to file your appeal?
The request must be filed with the MAC within 60 calendar days of the date you were notified of the decision made by the ALJ (Appeal Level 3). The MAC may give you more time if you have a good reason for missing the deadline. The decision you receive from the ALJ will tell you how to file this appeal, including who can file it.
How soon will the Council make a decision?
The MAC will first decide whether to review your case (it does not review every case it receives). If the MAC reviews your case, it will make a decision as soon as possible. If it decides not to review your case, you may request a review by a Federal Court Judge (see Appeal Level 5). The MAC will issue a written notice explaining any decision it makes. The notice will tell you how to request a review by a Federal Court Judge.
If the Council decides in your favor:
See the section “Favorable Decisions by the ALJ, MAC, or a Federal Court Judge” below for information about what we must do if our decision denying what you asked for is reversed by the MAC.
You have the right to continue your appeal by asking a Federal Court Judge to review your case if the amount involved meets the minimum requirement specified in the Medicare Appeals Council’s decision, you received a decision from the Medicare Appeals Council (Appeal Level 4), and:
- The decision is not completely favorable to you, or
- The decision tells you that the MAC decided not to review your appeal request.
How to file your appeal?
In order to request judicial review of your case, you must file a civil action in a United States district court within 60 calendar days after the date you were notified of the decision made by the Medicare Appeals Council (Appeal Level 4). The letter you get from the Medicare Appeals Council will tell you how to request this review, including who can file the appeal.
Your appeal request will not be reviewed by a Federal Court if the dollar value of the requested Part C medical care or service does not meet the minimum requirement specified in the MAC’s decision.
How soon will the Judge make a decision?
The Federal Court Judge will first decide whether to review your case. If it reviews your case, a decision will be made according to the rules established by the Federal judiciary.
If the Judge decides in your favor:
See the section “Favorable Decisions by the ALJ, MAC, or a Federal Court Judge” below for information about what we must do if our decision denying what you asked for is reversed by a Federal Court Judge.
If the Judge decides against you:
You may have further appeal rights in the Federal Courts. Please refer to the Judge’s decision for further information about your appeal rights.
Favorable Decisions by the ALJ, MAC, or a Federal Court Judge
This section explains what we must do if our initial decision denying what you asked for is reversed by the ALJ, MAC, or a Federal Court Judge.
- For a decision about Part C medical care or services, we must pay for, authorize, or provide the medical care or service you have asked for within 60 days of the date we receive the decision.