Certified Revenue Cycle Representative (CRCR) Practice Exam

Which level is NOT part of the Medicare fee-for-service appeal process?

1. A) Medical necessity review by an independent panel

2. B) Judicial review by a federal district court

3. C) Redetermination by a claims handling company

4. D) Review by state health departments

The correct answer is: D) Review by state health departments

The correct answer is that review by state health departments is not part of the Medicare fee-for-service appeal process. The Medicare appeal process consists of a series of defined levels that allow beneficiaries to appeal decisions related to their claims. The appeal process begins with a redetermination by the claims handling company, allowing for an initial review of the claim. If the beneficiary is dissatisfied with this decision, they can then pursue a reconsideration by a qualified independent contractor. This is followed by the option for a hearing before an administrative law judge and potentially a review by the Medicare Appeals Council. Finally, the process can culminate in judicial review by a federal district court. State health departments, while they may oversee various health services and programs, do not play a role in the Medicare fee-for-service specific appeals process. This is a federal program governed by the rules and regulations of the Centers for Medicare & Medicaid Services (CMS), and therefore the appeal process is strictly managed at the federal level without the involvement of state health departments.