Appeals Process

If you think Medicare should have paid for (or did not pay enough for) an item or service you received, you can file an appeal. If you request an appeal, ask your doctor or provider for any information related to the bill that might help your case. The last page of the Medicare Summary Notice (MSN) that you receive from Railroad Medicare explains your appeal rights. The page also explains how to file an appeal and gives the date that we must receive your appeal by. 

There are five different levels in the appeals process. If you don’t agree with the first level of appeal you can request the second level. If you still don’t agree you can request the third level and then the fourth, and finally the fifth. Each level must be requested in sequential order. It is important to remember that the decision letter you receive at each level of appeal will explain additional appeal rights you may have. You should read these decision letters carefully.

• First level – Redetermination – This is the first level of the appeals process and must be requested within 120 days from the date you received your MSN. We assume you received your MSN within five days from the date of the notice. To file an appeal, follow the instructions on your MSN and return the completed, signed form to our office at the following address:

Railroad Medicare – Palmetto GBA
Attn: Redeterminations
P. O. Box 10066
Augusta, GA 30999 

• Second level – Reconsideration – This is the second level of appeals and is requested if you are dissatisfied with the decision made during your first level of appeal. This must be requested within 180 days from the date of your redetermination decision. The second level of appeals is handled by the Qualified Independent Contractor (QIC), which is separate from Palmetto GBA. Information about the QIC is included on your Redetermination decision letter from Railroad Medicare. Reconsideration requests should be sent to the following address:

C2C Innovative Solutions, Inc. 
QIC Part B South
P. O. Box 45300
Jacksonville, FL 32232-5300 

• Third level – Administrative Law Judge (ALJ) – If you do not agree with the QIC’s decision made on your second level of appeal, you can request a hearing by an Administrative Law Judge. This request needs to be submitted within 60 days from the date of your reconsideration decision. For requests filed on or before December 31, 2023, the bill you are appealing must be more than $180.00. That amount will remain the same for requests filed on and after January 1, 2024. Details explaining where to send your request should appear on the reconsideration decision letter.
   
• Fourth level – Medicare Appeals Council – If you disagree with the ALJ’s decision made on your third level of appeal, you have 60 days after you get your decision to ask for a review by the Medicare Appeals Council. Follow the directions you got from the ALJ to ask for a review by the Medicare Appeals Council.
   
• Fifth level – Review by a Federal District Court – If you wish to appeal the decision of the Medicare Appeals Council on your fourth level of appeal, you have the right to request a review by a Federal district court. For requests filed on or before December 31, 2023, the bill you are appealing must be more than $1,850.00. That amount will decrease to $1,840 for requests filed on and after January 1, 2024. Follow the directions in the Medicare Appeals Council decision to request a review by a Federal district court. 

If you have questions about your Railroad Medicare claim, you can call our toll-free Customer Service Line at 800–833–4455, Monday through Friday, from 8:30 a.m. to 7 p.m. ET. For the hearing impaired, call TTY/TDD at 877–566–3572. This line is for the hearing impaired with the appropriate dial-up service and is available during the same hours Customer Service Representatives are available.