10% of Medicare beneficiaries have a claim denied. Here's how to appeal a decision

The good news: if you are denied coverage by Medicare, you have the right to appeal the decision.

The bad news: The same survey reported that 69% of consumers whose claims had been denied didn’t know they could appeal those decisions, and a large majority (85%) do not file appeals.

Here’s everything you need to know to appeal a Medicare decision.

When to consider appealing a denied claim

Before starting the process, consider whether your appeal is viable.

“Everybody’s situation is different,” says Jen Teague, Director for Health Coverage and Benefits at the National Council on Aging. “It’s worth appealing if a person truly believes they have a medically necessary need, or they’re going to be at risk if they’re discharged earlier than they think they should be, or they need specific care or treatment.”

Teague also strongly recommends having a conversation with the physician who provided the service.

“Does the doctor believe this is something the patient needs, and is the doctor willing to write a letter to include in the appeal with additional information to help make that case? If so, that is very important in the potential success of the appeal,” says Teague.

Appeals to Medicare may seem intimidating and complicated, which may be why 29% of calls in 2022 to the Medicare Rights Center’s National Helpline, according to an analysis of call data, were about denials and appeals. The free phone line, 800-333-4114, assists people with Medicare questions. The center receives 20,000 calls per year, and is open from Monday through Friday, from 9 a.m. to 3 p.m., Eastern time.

Certain types of denials are fairly common, says Sarah Murdoch, director of client services at the Medicare Rights Center who also heads up the helpline.

One is when your plan covers an annual service, and it appears that you have had the annual service more than once during that year.

“If you went for a mammogram screening in January and everything was clear, but you find a lump 10 months later and you need more screening, the coding would have to be different from the annual mammogram screening. If it wasn’t, your claim may have been denied, even though the procedure was medically necessary,” says Murdoch.

A typical appeal for prescription drugs, says Murdoch, is about quantity. For example, 60 pills are prescribed, but the plan says only 30 are covered each month.

Hospital stays may also generate a reason for an appeal, says Teague. “If a person is considered inpatient in a hospital, they may be eligible for rehabilitation days under Medicare. However, if a person is considered ‘under observation’ for a period of the stay in the hospital that person may not be eligible for rehab coverage under Medicare.”

If you think you are being discharged from the hospital too quickly, you can request an immediate review by your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). While they review your case, you can stay in the hospital at no charge.

You can also get an expedited appeal if you disagree with the decision that you no longer need services from a home health agency, outpatient rehabilitation facility, or skilled nursing facility.

How to file an appeal if you have original Medicare

If you think you have a case, here are the steps to take to appeal a denied claim:

  1. Once you receive a Medicare Summary Notice (MSN) in the mail that shows you were denied coverage, you have 120 days to file an appeal.
  2. To file an appeal, fill out a “Redetermination Request Form [PDF, 100 KB]” and send it to the company that handles claims for Medicare (the Medicare Administrative Contractor).
  3. Include this information in your appeal:
  • Your name, address, and the Medicare number on your Medicare card
  • A list of the items and/or services you disagree with on the MSN
  • An explanation of why you think the items and/or services should be covered. Even better, include a letter from your doctor, on your doctor’s letterhead, explaining why the items and/or services should be covered
  • The name of your representative, if you’ve appointed a representative (see below)
  • Any additional information that may help your case

Expect a decision within 60 days after the Medicare Administrative Contractor receives your request. If Medicare agrees to cover the item or service, it will be listed on your next MSN.

How to file an appeal if you have Medicare Advantage

Once you receive notice of a denied claim, you can appeal the decision by asking for a reconsideration and include the same information in your appeal as you would to appeal a claim under original Medicare.

You, a representative, or your physician may request a standard or expedited reconsideration.  If your physician requests the expedited reconsideration, plans are required to expedite the request.

Reconsideration requests must be filed with the health plan within 60 calendar days from the date of the denial notice. Standard requests are typically required in writing, although some plans may accept verbal requests. Check the Evidence of Coverage your plan sends you each year—which includes details about what’s covered and how much you’ll pay—to find out if your plan accepts verbal requests. Expedited requests can be made verbally or in writing.

Once a reconsideration request is received by the plan, it must respond no later than 72 hours for expedited requests, 30 calendar days for standard requests, or 60 calendar days for payment requests.

How to file an appeal if you have Medicare Part D (prescription drug plan)

The appeal process varies depending on whether you’ve already bought the drugs or not.

If you’ve already bought the drugs and want to get paid back, you or the prescriber must make the standard request in writing, through a letter or a completed Model Coverage Determination Request form. 

If you want coverage for a prescription you haven’t received yet, you or your prescriber can ask your plan for a coverage determination or an exception. You can make your request in writing, through a letter or a completed Model Coverage Determination Request form, or you can call your plan. If you ask for an exception, the prescriber must provide a statement detailing the medical reason why the exception should be approved. You can ask for an expedited request if your plan or prescriber determines that waiting for a standard response could seriously jeopardize your health, life, or ability to regain maximum function.

These are the response times for each type of request:

  • Expedited request: 24 hours
  • Standard service request: 72 hours
  • Payment request: 14 calendar days

Additional appeal requests

“If you don’t receive a favorable decision on your first appeal, you can continue appealing the decision,” says Teague. Medicare Advantage and Medicare Part D offer expedited responses at certain levels, but all of these review levels are available to original Medicare, Medicare Advantage, and Medicare Part D beneficiaries, says Teague:

  • Level 1: The original appeal request as described above
  • Level 2: A review by a “qualified independent contractor”
  • Level 3: A review and decision by the Office of Medicare Hearings and Appeals
  • Level 4: A review by an appeals council
  • Level 5: A judicial review by a federal district court

At each level of the appeal process, you should be provided with additional information about how you can appeal the decision to the next level if you do not agree with the decision provided in levels 1-4. Each review level may require a minimum dollar amount for the benefit being appealed, says Teague.

How to get help filing an appeal

If you need help filing an appeal, you can contact your State Health Insurance Assistance Program (SHIP).

You also have the option of appointing a representative to file an appeal on your behalf. The representative can be a friend, family member, attorney, financial advisor, doctor, or other advocate.

You can add a representative to your Medicare account online, or fill out an  Appointment of Representative form or a detailed written request, and send it to the Medicare Administrative Contractor or your Medicare health plan.

More on Medicare:

Source link

About The Author

Scroll to Top