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The analysis of any legal or medical billing is dependent on numerous specific facts — including the factual situations present related to the patients, the practice, the professionals and the medical services and advice. Additionally, laws and regulations and insurance and payer policies are subject to change. The information that has been accurate previously can be particularly dependent on changes in time or circumstances. The information contained in this web site is intended as general information only. It is not intended to serve as medical, health, legal or financial advice or as a substitute for professional advice of a medical coding professional, healthcare consultant, physician or medical professional, legal counsel, accountant or financial advisor. If you have a question about a specific matter, you should contact a professional advisor directly. CPT copyright American Medical Association. All rights reserved. CPT is a registered trademark of the American Medical Association.

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Appeals Level 4: Appeals Council 

Appeal Form DAB-101

A party may also file electronically on the Council's website: https://dab.efile.hhs.gov/mod/

The level of administrative review available to parties after the ALJ hearing decision or dismissal order has been issued, but before judicial review is available is Appeals Council review.

A party to the ALJ hearing may request review by the Appeals Council within 60 days after receipt of the notice of the ALJ’s hearing decision or dismissal. If a party requests the Appeals Council to review an ALJ’s decision, the Appeals Council conducts a de novo review of the decision and may adopt, modify, or reverse the ALJ’s decision, or remand the case to an ALJ for further proceedings.

Recommending Agency Referral of ALJ Decisions or Dismissals

CMS may refer a case to the Appeals Council for it to consider under its own motion review authority within 60 days after the date of the hearing decision or dismissal. This is known as an “agency referral”. The Appeals Council may adopt, modify, or reverse the ALJ’s decision, may remand the case to an ALJ for further proceedings, or may dismiss an agency referral request. For ALJ decisions issued by DHHS OMHA ALJs, the AdQIC will be responsible for reviewing ALJ decisions and determining whether an agency referral is appropriate. For all ALJ decisions issued by SSA ALJs, the contractor remains responsible for this activity.

Effectuation of Appeals Council Orders and Decisions

When a MAC receives an effectuation notice from the AdQIC regarding an Appeals Council decision that requires effectuation, it initiates effectuation within 30 days of its receipt of the effectuation notice, and completes effectuation within 60 days. Any questions regarding effectuation should be directed to the AdQIC for guidance.

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