QIC reconsideration decision (standard claims ladder): what it means and what to do

A Qualified Independent Contractor's written decision after an unfavorable MAC redetermination on a standard Medicare claim.

The QIC's reconsideration decision is the second, independent look at your claim — a different reviewer than the MAC that redetermined it.

60 days from receiving the QIC's or QIO's reconsideration decision (42 CFR § 405.1014), with the same 5-day receipt presumption.rule42 CFR 405.1002

The dollar amount still in dispute must meet a yearly minimum set by the Secretary — $200 for 2026 — to qualify for an ALJ hearing. Several denied claims can be combined to reach it if they involve similar or related services (42 CFR § 405.1006(e)).

The QIC is a genuinely separate organization from your MAC, not another department at the same contractor — its reconsideration is meant to be an independent second opinion, and its own written reasoning is worth reading closely before deciding whether a hearing is worth requesting.

If the reconsideration decision doesn't clearly address an argument you raised, that's worth flagging directly in the hearing request — an ALJ reviews the case fresh, but pointing out exactly what the QIC didn't address can still sharpen the argument.

Check the amount in controversy. The notice should state whether your case meets the dollar threshold to request an ALJ hearing — a real, yearly-adjusted minimum, not a formality.

Read the QIC's own reasoning. Same as the redetermination: find the specific rule or policy the QIC applied, not just the outcome.

Request a hearing if the amount qualifies. If the reconsideration is unfavorable and the amount in controversy is met, the next step is a hearing before an Administrative Law Judge.

File within your deadline. 60 days from receiving the QIC's or QIO's reconsideration decision (42 CFR § 405.1014), with the same 5-day receipt presumption.

None automatically — if the QIC misses its own 60-day deadline, you have the right to ask to escalate directly to OMHA, but you have to actually ask; nothing forwards on its own the way a missed MAC deadline can. 60 calendar days from when the QIC receives your timely request (42 CFR § 405.970). If the QIC can't meet that deadline, it must offer you the chance to escalate straight to OMHA instead of waiting (42 CFR § 405.970(e)(2)) — CaseWhy Appeals tells you the moment that right opens up.