In the process to appeal a Medicare claim denial, which sequence correctly describes the typical path?

• A. Start with an informal review with the plans only.
• B. File a redetermination with the MAC, then move to reconsideration by a QIC, and potentially to an Administrative Law Judge (ALJ) and higher levels.
• C. Submit a request directly to the Administrative Law Judge (ALJ).
• D. Appeal to the Centers for Medicare & Medicaid Services (CMS) first.

Answer: (B)

Medicare's claim appeals follow a staged, formal hierarchy designed to review a denial in orderly steps. The first step is a redetermination by the Medicare Administrative Contractor, which is a formal re-review of the denial at the plan level. If the result is still not favorable, the next step is a reconsideration by a Qualified Independent Contractor, an independent reviewer. If you still need help after that, you can request an Administrative Law Judge hearing, and potentially move to higher levels such as the Medicare Appeals Council and, ultimately, federal court. Other routes like an informal review with the plan only or jumping straight to the ALJ bypass the established sequence, so the described path—MAC redetermination, then QIC reconsideration, then ALJ and higher levels—is the standard sequence.