A physician who disagrees with a Medicare redetermination has 180 days to request reconsideration by a Qualified Independent Contractor (QIC), the second of Medicare's five appeal levels. That deadline matters, but a stricter rule matters more: absent good cause, evidence not submitted by the time the QIC issues its decision is generally barred from later consideration before an administrative law judge (ALJ). Whether a practice was audited by a Medicare Administrative Contractor, a RAC, or another contractor, what gets submitted, or fails to get submitted, at reconsideration effectively sets the record for the rest of the appeal.
The 180-Day Deadline to Request Reconsideration
Reconsideration is the second level of the Medicare Parts A and B appeals process, following the redetermination decision issued by the Medicare Administrative Contractor at Level 1. A party dissatisfied with that redetermination has 180 days from receipt of the redetermination notice to file a written reconsideration request with the assigned QIC. The QIC did not take part in the Level 1 decision. It conducts an independent review of the administrative record, including the initial determination and the redetermination.
What the QIC Reviews and What Must Be Submitted
The reconsideration request must clearly explain why the practice disagrees with the redetermination and must be accompanied by any evidence or allegations of fact or law related to the disputed issues, including medical records, physician certifications, and any documentation the extrapolation methodology or the applicable local coverage determination requires. The QIC generally sends its decision to all parties within 60 days of receiving the request. Submitting additional evidence after filing automatically extends that 60-day clock, so a practice that trickles in records piecemeal is also delaying its own decision.
The Evidence Rule That Follows You to the ALJ
Under 42 C.F.R. § 405.966(a)(2), absent good cause, failure to submit all evidence, including documentation the redetermination notice already requested, before the QIC issues its reconsideration precludes that evidence from being considered later in the appeal. The same principle is enforced again at Level 3. Under 42 C.F.R. § 405.1018, new evidence offered to the ALJ must be accompanied by a written statement explaining why it was not submitted to the QIC earlier. Without that statement, the ALJ does not consider the evidence at all.
The QIC reconsideration is not a formality on the way to an ALJ hearing. It is the last point at which a practice can add medical records, physician certifications, or billing documentation to the record without proving good cause for the delay.
Good cause is a narrow exception, not a fallback plan. An ALJ will generally recognize it where the new evidence addresses an issue the QIC's decision did not identify as material, where the practice made reasonable attempts to obtain the record before the QIC decided, or where the evidence was actually submitted to the QIC or another contractor before the decision issued. A practice that simply held back records does not meet that standard.
Escalating When the QIC Misses Its Deadline
If the QIC cannot complete the reconsideration on time, it must notify the parties and offer the option to escalate the appeal directly to the Office of Medicare Hearings and Appeals for an ALJ hearing. Escalation can shorten the timeline, but it carries the same tradeoff: the record escalates as it stands, and the recoupment and repayment posture the practice is fighting does not pause simply because the appeal moved up a level.
Why Early Legal Counsel Is Critical
It is critical that physicians and practices promptly retain experienced healthcare defense counsel upon receiving an adverse redetermination or opening a QIC reconsideration, and not wait to see how the ALJ hearing unfolds. Early legal intervention can protect the practice's rights, ensure the reconsideration request identifies every disputed issue and every supporting record, and preserve the evidence needed if the matter proceeds further. Health Law Alliance's guide on when to engage a Medicare audit attorney walks through the decision points in more detail. Delaying representation into the reconsideration stage, when the evidentiary record is being locked in, can significantly affect the outcome of the appeal.
How Health Law Alliance Can Help
Health Law Alliance represents physicians and practices through every level of the Medicare appeals process, drawing on the firm's experience with 2,000+ audits overseen on behalf of healthcare providers. The firm's attorneys build the reconsideration record with the ALJ hearing in mind from the outset, so a practice is not left arguing good cause for evidence that should have gone to the QIC. Physicians who have received a Medicare redetermination or are preparing a QIC reconsideration can contact Health Law Alliance's Medicare audit defense team for a free, confidential consultation.
