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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 5: Federal Court

Following issuance of a decision by the Appeals Council, a party may request judicial review of the Appeals Council’s decision. A MAC cannot accept requests for judicial review. The appellant must file the complaint with the U.S. District Court.

If a party files a request for judicial review with a MAC, the MAC must immediately notify the appellant that the complaint must be filed with the appropriate U.S. District Court (i.e., the district court for the judicial district in which the party resides or where such individual, institution, or agency has its principal place of business). However, the appellant is responsible for determining where the complaint must be filed. MACs shall not forward the complaint to a district court as a courtesy to the appellant.

Amount in controversy: $1,560

Effectuation of U.S. District Court Decisions

The U.S. District Court may remand the case to the Appeals Council or ALJ for further proceedings. In rare cases, the U.S. District Court will issue an order that will require effectuation by a MAC. In this situation, the MAC immediately contacts its Contracting Officer’s Representative/Contractor Manager for further instructions before taking any action.

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