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<h1 class="page-title">Procedimientos de apelaciones de Medicare</h1>








  
  
    

  
      





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          <div  class="field__item usa-prose"><p><strong>Si un ALJ emitió una orden de desestimación después de que un Contratista Independiente Calificado (Qualified Independent Contractor, QIC), una Entidad de Revisión Independiente (Independent Review Entity, IRE) o una Organización de Mejoramiento de la Calidad (Quality Improvement Organization, QIO) realizó una determinación de reconsideración, <em>estos procedimientos se aplican a su apelación</em>:</strong></p>

<p>Si no está de acuerdo con la desestimación del Juez de Derecho Administrativo (Administrative Law Judge, ALJ), puede apelar ante el Consejo de Apelaciones de Medicare (Medicare Appeals Council, MAC). Otras partes también pueden apelar. Denominamos una apelación ante el MAC como “solicitud de revisión”. El organismo de Medicare también puede solicitar al MAC que revise la desestimación del ALJ.</p>

<p>Si el MAC no revisa la desestimación del ALJ sobre la apelación de una parte o a solicitud del organismo de Medicare, la determinación de reconsideración del QIC o de la QIO será vinculante.</p>

<p>Usted puede designar a un abogado u otra persona para que lo represente. Los grupos de asistencia legal pueden prestar servicios jurídicos sin ningún costo.</p>

<p><strong>Qué debe incluir en su apelación</strong><br>
Su apelación debe identificar las partes de la desestimación del ALJ con las cuales está en desacuerdo y una explicación del motivo de su desacuerdo. Por ejemplo, si cree que la desestimación del ALJ es incoherente con una ley, reglamentación, resolución de un organismo de Medicare u otra autoridad, debe explicar el motivo por el cual la desestimación es incoherente con dicha autoridad.</p>

<p>Debe utilizar el formulario DAB-101 para apelar.  También puede apelar por escrito si proporciona:</p>

<ul>
	<li>el nombre del beneficiario;</li>
	<li>el número de Medicare del beneficiario;</li>
	<li>el artículo o servicio controvertido;</li>
	<li>la fecha del artículo o servicio;</li>
	<li>la fecha de la desestimación del ALJ; y</li>
	<li>su nombre, y según corresponda, el nombre de su representante.</li>
</ul>

<p><em><strong>Envíe una copia de la desestimación con su apelación.</strong></em></p>

<p><strong>Cómo presentar una apelación</strong><br>
Su apelación debe presentarse, es decir recibirse por el MAC, <em><strong>dentro un plazo de 60 días</strong></em> después de la fecha en que reciba la orden de desestimación del ALJ. El MAC supondrá que usted recibió la orden de desestimación cinco días después de la fecha que consta en la misma, a menos que usted nos demuestre que la recibió más tarde. Si presenta la apelación tarde, debe demostrar que la demora tuvo una justa razón. </p>

<p>Envíe por correo la apelación a:</p>

<p>Department of Health and Human Services<br>
Junta Departamental de Apelaciones, MS 6127<br>
Medicare Appeals Council<br>
330 Independence Avenue, S.W.<br>
Cohen Building, Room G-644<br>
Washington, D.C.  20201</p>

<p>O puede enviar por fax la apelación al (202) 565-0227. Si envía un fax, no nos envíe también una copia por correo postal.  <em><strong>Deberá enviar una copia de su apelación a las demás partes e indicar que se envió una copia a todas las partes, incluyendo a todos los beneficiarios, en la solicitud de revisión. Para los reclamos que comprenden múltiples beneficiarios, podrá presentar una copia de las cartas de presentación emitidas o una planilla con los beneficiarios y los domicilios de quienes recibieron una copia de la solicitud de revisión.</strong></em></p>

<p>Las reglamentaciones de Medicare en el Título 42 del Código de Reglamentos Federales (Code of Federal Regulations, C.F.R.), Parte 405, Literal I, se aplican a este caso. Las resoluciones del organismo de Medicare también pueden aplicarse. Si tiene alguna pregunta acerca del MAC, puede llamar al (202) 565-0100.</p>

<p><strong>Medidas del Consejo de Apelaciones de Medicare</strong><br>
El MAC puede denegar, desestimar o aceptar su apelación. Si el Consejo acepta su apelación, puede enviar el caso de regreso a un ALJ para que tome medidas adicionales. También puede emitir una sentencia en su caso. El MAC limitará su revisión a las cuestiones planteadas en la apelación, salvo que la apelación sea presentada por un beneficiario no representado.</p></div>
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