When you know your Medicare rights, you can try to get coverage approval through an appeal if denied Medicare benefits. Appealing a claim can be difficult; however, with the right knowledge, anyone can do it.
It’s possible to disagree with a coverage decision made by Medicare, your health plan or Prescription Drug Plan. Know your rights, if a service, device, or prescription is denied for coverage, then you can file a Medicare appeal.
You can file an appeal if you don’t agree with the total cost amount. Try to understand the letters and notices sent when you experience coverage denial.
An appeal can also be filed if your plan stops providing you with what you believe you still need. Talk to your doctor about receiving any information that could help your case.
The process for an appeal depends on whether you’re filing an appeal with a Prescription Drug Plan, Medicare Advantage plan or with Traditional Medicare. So, if the denied item is a prescription, you should contact the company that covers your prescriptions, not Medicare.
The First Step in Filing a Medicare Appeal
Before you file an appeal, you need to determine where to send the appeal. If you have Traditional Medicare and they denied coverage, then you will file your appeal with Medicare.
Medicare sends quarterly statements known as a Medicare Summary Notice (MSN); this lists all your healthcare expenses billed to Medicare. This statement will also show if a service was fully or partially denied. Your MSN will have instruction on how to file an appeal.
We help our clients with any claims issue, every step of the way. Have a Medigap plan with another company? Contact your State Health Insurance Assistance Program (SHIP) for information about filing an appeal.
If you have stand-alone Part D Prescription Drug coverage, file an appeal through your Part D company.
For those with a Medicare Advantage plan or a Medicare Advantage Prescription drug plan, you will need to look at the information in your evidence of coverage if denied. If you no longer have the document, you may be able to find the information online. You could also contact the plan directly by calling the phone number on your member ID card.
When you know who to contact regarding your appeal, it’ll save you quite a bit of time on the phone. If you enroll in a Medicare Supplement plan through MedicareFAQ, you’ll have a whole team of client-focused representatives. We offer plans from many different companies and find the most suitable option for you.
Know You’re Rights When an Appeal is Denied
You have the right to file another appeal if you’re not successful the first time you filed. It’s vital that each appeal happens timely; there is a timeframe for when to file and when you will receive a decision notice.
If you can’t submit an appeal in a timely fashion, then you will want to check your eligibility for a good cause extension.
There are three ways you can file a Medicare appeal:
- Download the Redetermination Request Form. Complete the form and send it to the Medicare contractor at the address on your Medicare Summary Notice.
- Send a request to the company that handles Medicare Claims. The address and information will be in the MSN “Appeals Information” section.
- Include your name and Medicare ID number
- Specific items or services you’re requesting redetermination for and the specific date of service
- Give an explanation on why you don’t agree with the denial
- Sign the document
- Send the appeal to the company that handles your Medicare Claims.
- Be sure to circle each applicable item or service you disagree with and write in detail why you disagree with the decision on a separate sheet of paper.
- Include your address, name, cell phone number, and your Medicare ID number.
- Include information from your health care provider that will help your case.
- Sign the MSN on the signature lines
The Second Step in Filing a Medicare Appeal
Within 60 days of your request, you will receive a Medicare Redetermination Notice, this will include the contractor’s decision and will either come as a separate letter or as part of your quarterly MSN.
If you disagree with the decision, you have 180 days after you receive the notice to advance to a Level 2 appeal. You need to submit a new form, called the Medicare Reconsideration Request Form.
When you request a second reconsideration on your claim, an independent review organization or qualified independent contractor will assess your appeal. If your appeal is denied a second time and you appeal again, then you will likely want an attorney to represent you.
The form for Level 3 is a Request for an Administrative Law Judge (HA-501) Hearing or Review of Dismissal. Third level appeals usually take place before an administrative law judge in a conference room. If the appeal is still denied at this point, you can present the appeal to the Medicare Appeals Council.
The federal court is the final level of appeal, you typically have 60 days to file appeals before an ALJ, the Medicare Appeals Council and to the federal court. To get a judicial review, you must meet a minimum dollar amount, which changes each year. You may combine claims to meet this amount.
What if Your Appeal is Approved
There are plenty of websites that will tell you about what happens if your claim is denied; but if your claim is approved, what do you do next? How will you know you’ve been approved? Do you need to notify anyone of the approval?
If your claim is approved Medicare will send you a letter to notify you, the information should also be available on your MyMedicare.gov account. You won’t need to do anything once the appeal is approved. Medicare or the insurance company will pay the claim like usual and you can relax knowing you were successful in your appeal.
Learn About Your Medicare Rights if Denied Coverage
When you purchase an insurance policy through MedicareFAQ, our Client Care Team will be here every step of the way to coach you on how to file your appeal. They will tell you the best things to say or do to give you the best chance at approval.
Knowing your Medicare rights if you’re denied coverage gives you a better chance of coverage.
Every person goes through the same process, it’s a waiting game. Unfortunately, the insurance agent can’t speed up the process, but we can help you find the appeal forms and give our advice on how to fill out the forms.
We will do our best to help you, although it’s important to remember that you can’t always win. Our agency is available to help any existing policyholders with claims appeals and give you the best chance at winning.
We can’t assist those who aren’t enrolled through us, though we hope these tips can help you go through the appeals process easily.
If you want to learn more about our policies or our Client Service Team, please contact us at the phone number above. If you want to enroll in one of our many Medicare Supplement plans online, you can compare rates with our online rate form!