Medicare Reconsideration by a QIC: How to Add New Evidence at Level 2

If your Medicare redetermination is unfavorable, the next step is a reconsideration by a Qualified Independent Contractor (QIC). The reconsideration is the second level of the Medicare fee-for-service appeals process, and it is often described as the most important level for building your case.

That is because of a rule many providers overlook: under Medicare's "full and early presentation of evidence" requirement, evidence that providers and suppliers do not submit by the time the QIC issues its reconsideration may be excluded from consideration at the Administrative Law Judge (ALJ) level and beyond, unless they show good cause for not submitting it earlier. In practical terms, Level 2 is usually the last chance to put all of your evidence into the record.

This article explains what a QIC reconsideration is, who the QICs are, the filing deadlines, how to file, what to include, how to add new evidence effectively, how the QIC decides, what happens if the QIC misses its deadline, and how to prepare for the next level. It is educational and does not replace legal or professional advice.

What Is a QIC Reconsideration?

CMS describes a reconsideration as an independent review of the administrative record by a QIC. QICs are independent contractors that did not participate in the initial determination or the redetermination. The reconsideration is governed by 42 CFR 405.960 through 405.978.

For medical necessity issues, QIC reconsiderations involve review by a panel of physicians or other appropriate health care professionals, and the decision is based on clinical experience, the patient's medical records, and medical, technical, and scientific evidence of record.

There is no minimum amount in controversy for a reconsideration.

Who Are the QICs?

CMS lists the following QIC jurisdictions and contractors:

• Part A East: C2C Innovative Solutions.

• Part A West: MAXIMUS Federal Services.

• Part B North: C2C Innovative Solutions.

• Part B South: C2C Innovative Solutions.

• DME: MAXIMUS Federal Services.

CMS states that requests can be submitted in writing, by fax, or through the QIC appeals portal, depending on the QIC. CMS also notes that some MAC portals can route certain second-level appeals to the QIC electronically. Always use the QIC name and address listed in your redetermination notice.

Deadlines

180 Days to File

CMS explains that the appellant has 180 days from the date of receipt of the redetermination decision to file a reconsideration request. The redetermination decision may be issued as a Medicare Redetermination Notice, a Medicare Summary Notice, or a remittance advice. Receipt is presumed to be five days after the date on the notice unless there is evidence to the contrary.

60 Days to Continue Limiting Recoupment

For overpayments, Section 1893(f)(2) of the Social Security Act and 42 CFR 405.379 limit recoupment while a timely reconsideration is pending, but only if the reconsideration is filed within 60 days of the redetermination decision. Filing after 60 days but within 180 days preserves your appeal rights, but recoupment may begin.

QIC Decision Timeframe

CMS states that the QIC generally sends its decision to all parties within 60 days of receiving the request. Submitting additional evidence after filing may extend this timeframe, but documentation the QIC requested does not extend it.

Late Filing

If you miss the 180-day deadline, you may ask the QIC to extend the filing period for good cause. Form CMS-20033 includes a section to explain late filing.

How to File

Form CMS-20033

CMS states that the reconsideration request must be in writing, using Form CMS-20033, Medicare Reconsideration Request Form, or a written request that contains:

• The beneficiary's name.

• The beneficiary's Medicare number.

• The specific services, items, and dates of service.

• The name of the party or the party's authorized or appointed representative.

• The name of the contractor that made the redetermination.

CMS also asks appellants to include any missing documentation identified in the redetermination notice, to explain why they disagree with the redetermination, and to attach a copy of the redetermination notice or remittance advice and other relevant documents.

Submission Methods

Depending on the QIC, you may submit by mail, fax, or the QIC appeals portal. Some MAC portals can route certain appeals electronically. esMD also supports second-level appeal submissions to QICs.

What You Do Not Need to Resend

CMS notes that information already submitted to the MAC does not need to be resubmitted to the QIC, because the MAC forwards the case file. However, many providers choose to include key documents again, clearly organized, to make sure the QIC has everything and can follow the argument.

The Full and Early Presentation of Evidence Rule

What the Rule Says

Under Medicare's appeals regulations, providers, suppliers, and beneficiaries represented by providers or suppliers must present all evidence for the appeal by the end of the reconsideration process. CMS explains that documentation not submitted at the reconsideration level may be excluded from consideration at later levels of appeal unless good cause is shown. At the ALJ level, 42 CFR 405.1028 governs whether new evidence submitted by a provider or supplier may be considered, and it generally requires a showing of good cause.

What Counts as Good Cause

Under the ALJ rules, good cause for new evidence may be found in limited circumstances, such as when new evidence is material to an issue first identified in the QIC's reconsideration, or when the provider was unable to obtain the evidence before the QIC issued its decision despite making reasonable attempts. Do not count on good cause. Plan to put everything in the record at Level 2.

Why It Matters

If you lose at reconsideration and missing evidence would have changed the outcome, you may not be able to introduce that evidence at the ALJ hearing. That can make the difference between winning and losing.

How to Add New Evidence Effectively

Step 1: Read the Redetermination Decision Carefully

The redetermination notice explains why the MAC upheld the denial and often identifies missing documentation. Make a list of every gap the MAC identified.

Step 2: Gather Every Missing Document

Search thoroughly for:

• Orders, referrals, and documentation of intent to order.

• Certifications, recertifications, and plans of care.

• Face-to-face encounter documentation.

• Progress notes before, during, and after the service.

• Test results, imaging, and reports.

• Nursing, therapy, and aide notes.

• Medication administration records.

• Proof of delivery.

• Signature logs and appropriate signature attestations.

• Records from referring practitioners, hospitals, and other facilities.

• Advance Beneficiary Notices.

Step 3: Obtain Third-Party Records Early

Records from referring practitioners or facilities often make the difference in medical necessity appeals. Request them immediately and document every request, including dates and responses. If you cannot obtain them despite reasonable efforts, that documentation may help support good cause later.

Step 4: Add Clinical and Policy Support

Consider adding:

• A letter from the treating physician explaining the clinical rationale, consistent with and supported by the contemporaneous medical record. Remember that CMS does not treat physician attestations alone as sufficient proof of medical necessity, so the letter should explain and point to the record rather than replace it.

• Relevant clinical literature or guidelines that support the service, when the denial is based on clinical judgment.

• Copies or citations of the applicable NCD, LCD, billing and coding article, and manual provisions in effect on the date of service.

Step 5: Address Signature and Authentication Issues

Include signature logs for illegible signatures and, where appropriate, signature attestations from the authors of entries other than orders.

Step 6: Organize the Evidence

• Start with Form CMS-20033 or the written request.

• Add a cover letter explaining the disagreement.

• Include the redetermination notice.

• Add an index and number all pages.

• Separate new evidence from previously submitted evidence, and label new evidence clearly.

Step 7: Submit Evidence With the Request When Possible

Submitting all evidence with the request avoids extending the QIC's timeframe and ensures it is considered. If you must submit additional evidence after filing, do so as soon as possible and before the QIC issues its decision.

How to Write the Reconsideration Request Letter

A reconsideration letter follows a similar structure to a redetermination letter, but it should directly address the MAC's reasoning:

1. Identification: provider, beneficiary, Medicare number, claim number, dates of service, redetermination decision date, and QIC name.

2. Request: state that you are requesting reconsideration and the relief sought.

3. Summary of prior decisions: briefly summarize the initial denial and the redetermination decision.

4. Points of disagreement: explain specifically where the MAC erred.

5. New evidence: describe each new document and how it addresses the MAC's findings, with page references.

6. Coverage requirements and analysis: list each requirement and show how the complete record satisfies it.

7. Alternative arguments: limitation of liability under Section 1879, provider without fault under Section 1870 for overpayments, partial payment for a lower level of service, or errors in applying policy.

8. Statistical sampling issues: if the overpayment was extrapolated, state your objections to the sampling and extrapolation and include any statistician's report.

9. Requested outcome.

10. Enclosures and signature.

An Evidence Inventory Checklist for Level 2

Before filing the reconsideration, create an inventory of all evidence for each claim:

• Documents submitted with the original ADR response, if any.

• Documents submitted with the redetermination.

• Documents the MAC identified as missing.

• New documents obtained for the reconsideration.

• Third-party records requested, with request dates and responses.

• Policy citations and clinical references.

• Expert reports, such as a statistician's analysis.

• Signature logs and attestations.

For each requirement in the applicable policy, note which document satisfies it and where. If any requirement has no supporting document, decide whether more evidence exists or whether an alternative argument is needed. This inventory also becomes valuable if the case proceeds to an ALJ hearing.

Writing an Effective Treating Practitioner Letter

A letter from the treating physician or practitioner can help explain clinical reasoning, but it must be used carefully:

• Base the letter on the contemporaneous medical record and cite specific entries.

• Explain why the service was reasonable and necessary for this patient at that time.

• Describe the patient's condition, prior treatments, and the expected benefit of the service.

• Avoid conclusory statements such as "the service was medically necessary" without explanation.

• Do not introduce new clinical facts that do not appear in the record.

• Have the practitioner sign and date the letter.

CMS's Program Integrity Manual explains that physician attestations by themselves do not provide sufficient documentation of medical necessity. A letter is most useful when it helps the reviewer understand the existing record.

Reconsiderations of Extrapolated Overpayments

For overpayments based on statistical sampling, the reconsideration is a critical time to:

• Appeal each sampled claim you believe was paid correctly.

• Submit a statistician's analysis of the sampling methodology.

• Identify specific errors in the sampling frame, sample selection, or calculations.

Because new evidence may be excluded at the ALJ level absent good cause, statistical expert reports should be submitted at the reconsideration level. At the ALJ level, appellants who disagree with how a statistical sample or extrapolation was conducted must also state their reasons in the request for hearing.

What Happens After the QIC Decides

Favorable Decision

If the QIC reverses the denial, the MAC will effectuate the decision, generally by paying the claim or adjusting the overpayment.

Unfavorable or Partially Favorable Decision

You may request an ALJ hearing within 60 days of receiving the reconsideration decision, if the amount in controversy is met. For 2026, the ALJ threshold is $200. Note that the limitation on recoupment generally ends after the reconsideration decision, so recoupment of an overpayment may begin even if you request an ALJ hearing. Interest may be payable to the provider on recouped amounts if the provider ultimately prevails at a later level, under applicable rules.

QIC Dismissal

CMS explains that a QIC may dismiss a reconsideration request for reasons such as withdrawal, late filing without good cause, improper representative appointment, or the requestor not being a proper party. If you disagree with a dismissal, you may request OMHA review within 60 days of receipt of the dismissal, or ask the QIC to vacate the dismissal within six months of the date the dismissal was mailed.

Escalation if the QIC Misses Its Deadline

CMS states that if the QIC cannot complete its decision within the applicable timeframe, it must notify the parties and advise the appellant of the right to escalate the appeal to OMHA. Escalation requires a written request to the QIC, following the instructions in the notice. Escalation can move the case forward faster, but it also means the case goes to the ALJ without a QIC decision. Weigh this carefully, considering whether your evidence is complete.

Common Mistakes at Level 2

• Missing the 60-day deadline to continue limiting recoupment.

• Missing the 180-day filing deadline.

• Failing to submit evidence the MAC identified as missing.

• Holding back evidence for the ALJ hearing.

• Not obtaining referring practitioner records.

• Relying on physician letters without supporting contemporaneous records.

• Failing to address the MAC's specific reasoning.

• Not raising statistical sampling objections or submitting expert reports.

• Sending the request to the wrong QIC.

• Submitting disorganized evidence without an index.

A Hypothetical Example

A home health agency's claim was denied at redetermination because the MAC found that the certifying physician's records did not support homebound status. The agency's initial submission included only its own visit notes and the plan of care.

For the reconsideration, the agency requests the certifying physician's office notes and the discharge summary from the patient's recent hospitalization. Both document that the patient required a walker and assistance to leave home, experienced shortness of breath with minimal exertion, and left home only for medical appointments. The agency's reconsideration letter explains that these records, which were not before the MAC, directly address the MAC's finding, and it lists each homebound criterion with page references. The QIC reverses the denial.

Because the agency added the evidence at Level 2, it would also have been part of the record if the case had gone to an ALJ.

Preparing for a Possible ALJ Hearing

Even while pursuing the reconsideration, prepare for the next level:

• Build a complete record now.

• Identify potential witnesses, such as the treating physician or a clinical expert.

• Keep a list of all evidence submitted and when.

• Track all deadlines.

• If statistical sampling is involved, keep your statistician engaged.

Frequently Asked Questions

How long do I have to request a reconsideration?

180 days from receipt of the redetermination decision. For overpayments, file within 60 days to continue limiting recoupment.

Can I add new evidence at reconsideration?

Yes, and you should. Evidence not submitted at the reconsideration level may be excluded at later levels unless good cause is shown.

Do I need to resend documents I already gave the MAC?

CMS states that information already submitted to the MAC does not need to be resubmitted, but many providers include key documents again for clarity.

How long does the QIC take?

Generally 60 days from receipt of the request. Additional evidence submitted after filing may extend this timeframe.

What if the QIC is late?

The QIC must notify you and advise you of the right to escalate the appeal to OMHA.

Can I request a hearing with the QIC?

No. The QIC reconsideration is an on-the-record review. The first opportunity for an oral hearing is at the ALJ level.

What if I cannot get a referring physician's records before the QIC decides?

Keep documenting your requests. If you later need to submit the records at the ALJ level, evidence of reasonable attempts to obtain them may support a good cause argument, but there is no guarantee it will be accepted.

Does the QIC follow LCDs?

QICs apply Medicare statutes, regulations, NCDs, and CMS policy, and generally follow applicable LCDs and manual provisions. Make sure your arguments address the policies the QIC will apply.

Can the QIC reverse only part of a denial?

Yes. The QIC may issue a fully favorable, partially favorable, or unfavorable decision, and may find that documentation supports a lower level of service than billed.

Should I include the same evidence I sent to the MAC?

CMS states that it is not required, but including key documents in an organized packet can help the QIC follow your argument.

Conclusion

The QIC reconsideration is the second level of Medicare appeals and, for providers and suppliers, usually the last opportunity to add evidence without having to show good cause. A successful reconsideration directly addresses the MAC's reasoning, fills every documentation gap, includes referring practitioner records and policy support, raises statistical sampling objections when relevant, and is filed on time, within 60 days for overpayments to continue limiting recoupment. By treating Level 2 as the moment to complete the record, providers position themselves for success at reconsideration and at every level that follows.

How HealthBridge Can Help

HealthBridge is a healthcare management consulting firm that helps providers analyze redetermination decisions, identify and obtain missing evidence, prepare reconsideration requests, coordinate with clinical and statistical experts, and manage appeal deadlines through every level. If you need help preparing a Level 2 reconsideration, please get in touch with us. We will be happy to help you with this topic.

References

• Centers for Medicare & Medicaid Services. Second Level of Appeal: Reconsideration by a Qualified Independent Contractor. https://www.cms.gov/medicare/appeals-grievances/fee-for-service/second-level-appeal

• Centers for Medicare & Medicaid Services. Form CMS-20033, Medicare Reconsideration Request Form. https://www.cms.gov/medicare/cms-forms/cms-forms/downloads/cms20033.pdf

• Centers for Medicare & Medicaid Services. Original Medicare (Fee-for-Service) Appeals. https://www.cms.gov/medicare/appeals-grievances/fee-for-service

• Centers for Medicare & Medicaid Services. QIC Appeals Portal. https://qicappeals.cms.gov/

• Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual, Chapter 29, Appeals of Claims Decisions. https://www.cms.gov/regulations-and-guidance/guidance/manuals/downloads/clm104c29.pdf

• Federal Register. Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2026 (December 4, 2025). https://www.govinfo.gov/content/pkg/FR-2025-12-04/html/2025-21879.htm

• Electronic Code of Federal Regulations. 42 CFR Part 405, Subpart I, Determinations, Redeterminations, Reconsiderations, and Appeals Under Original Medicare. https://www.ecfr.gov/current/title-42/chapter-IV/subchapter-B/part-405/subpart-I

• Electronic Code of Federal Regulations. 42 CFR 405.966, Evidence to Be Submitted With the Request for Reconsideration. https://www.ecfr.gov/current/title-42/section-405.966

• Electronic Code of Federal Regulations. 42 CFR 405.972, Withdrawal or Dismissal of a Request for a Reconsideration. https://www.ecfr.gov/current/title-42/section-405.972

• Electronic Code of Federal Regulations. 42 CFR 405.1028, Prehearing Case Review of Evidence Submitted by the Appellant. https://www.ecfr.gov/current/title-42/section-405.1028

• Electronic Code of Federal Regulations. 42 CFR 405.379, Limitation on Recoupment of Provider and Supplier Overpayments. https://www.ecfr.gov/current/title-42/section-405.379

• U.S. Social Security Administration. Social Security Act, Section 1869, Determinations; Appeals. https://www.ssa.gov/OP_Home/ssact/title18/1869.htm

• U.S. Social Security Administration. Social Security Act, Section 1893, Medicare Integrity Program. https://www.ssa.gov/OP_Home/ssact/title18/1893.ht