What is the correct sequence for the five levels of RAC appeals?

• A. Redetermination, Reconsideration, Appeals Council Review, Administrative Law Judge Hearing, Final Judicial Review
• B. Redetermination, Administrative Law Judge Hearing, Reconsideration, Appeals Council Review, Final Judicial Review
• C. Reconsideration, Redetermination, Administrative Law Judge Hearing, Final Judicial Review, Appeals Council Review
• D. Redetermination, Reconsideration, Administrative Law Judge Hearing, Appeals Council Review, Final Judicial Review

Answer: (D)

The sequence follows a stepwise, escalating review process for RAC decisions. Start with redetermination, the first level of review handled by the original Medicare contractor. If still unresolved, the next step is reconsideration, which is handled by a different contractor to provide an independent second look. After those internal reviews, the formal Administrative Law Judge (ALJ) hearing is held, where evidence is presented and a decision is made in a quasi-trial setting. If either party disagrees with the ALJ decision, the Appeals Council reviews it to determine if the decision should be affirmed, revised, or sent back for further consideration. If all administrative levels are exhausted or denied, the case proceeds to Final Judicial Review in federal court. This order keeps ALJ hearings before Appeals Council review, and federal court review only after all CMS administrative avenues have been exhausted.

Other sequences place the ALJ hearing before reconsideration, or place Appeals Council Review before the ALJ decision, or move Final Judicial Review ahead of earlier steps, which does not align with how RAC appeals are structured.