If Medicare denies coverage for a healthcare service, item, or medication, you have a right to appeal. You can also appeal if a hospital or skilled nursing facility discharge you before you are ready. You have this right whether your claim relates to Part A, Part B, a prescription plan, or Medicare Advantage.
What is the Medicare Appeals Process?
Medicare has both an appeal process and a grievance process. If you have problems with the quality of care you receive, you can file a grievance or complaint. If you disagree with Medicare’s decision regarding coverage and payment, you can file an appeal. Also, expect to fill out Medicare forms.
Medicare Rights and Protections
Medicare processes more than a billion claims every year, and there will inevitably be mistakes and oversights. Knowing your Medicare rights and protections can help you navigate the health program more easily.
But it’s up to beneficiaries to file an appeal if a service didn’t have coverage when it was supposed to have coverage.
You can appeal if Medicare or your plan denies:
Request to get a service, item, or medication covered.
Request to change the amount you have to pay for a service, item, or drug.
How Do I File a Medicare Appeal?
The appeals process starts with your Medicare Summary Notice or MSN–the document you get in the mail every three months. MSN explains the status of your recent healthcare claims. If Medicare denies a claim, you can file an appeal. You can file an appeal by submitting a Redetermination Request form to the company on the last page of your MSN. You can also write a letter to appeal Medicare’s decision.
If you make a written request instead of using the form, include the following information:
Your name and address
Your Medicare card number
A copy of the MSN, with circles around the items you dispute
The reason you think the circled items should be covered
Other information or documents that may help your case, including medical records and doctors’ notes
If you have Medicare Advantage, the procedure is similar, but you’ll file your claim directly with your plan. Use the instructions on the denial notice or explanation of the benefits you get from your policy.
For prescription drug appeals, you can submit a written request to your plan. You can appeal a decision relating to a drug you’ve already paid for, or one you haven’t gotten.
How long does a Medicare appeal take?
You can expect a decision on your Medicare appeal within about 60 days. Officially known as a “Medicare Redetermination Notice,” the decision may come in a letter or an MSN.
Medicare Advantage plans typically decide within 14 days. Prescription plans usually respond within 72 hours.
If you are disputing a hospital discharge, you can file an expedited appeal. An expedited appeal may also be available if Medicare suddenly stops covering services you are currently receiving.
What if your Medicare appeal is approved?
If your appeal is approved, Medicare or your plan will pay the Medicare-allowed amount of the claim. You don’t need to do anything further.
Know Your Rights When an Appeal is Denied
If your appeal is denied, you can make additional appeals. While your first appeal is decided by the same organization that processed the original claim, other appeals are heard by third parties involved in the initial decision. There are five levels of appeals.
What Are the Five Steps in the Medicare Appeals Process?
The full Medicare appeals process has five levels. At the end of each step, you’ll receive a notice explaining the procedure for appealing to the next level.
Here are the five levels of appeals:
The original appeal goes to the company that handles Medicare claims. This company is listed on the last page of your MSN.
Reconsideration by a Qualified Independent Contractor. At the second level, an independent contractor reconsiders the coverage decision. The contractor was not involved in the original claim processing.
Appeal Hearing before the Office of Medicare Hearings. At this level, an administrative law judge hears your claim. At the hearing, you can present facts and testimony. After reviewing all the information, the judge will make a new decision on your request. Your claim must be for at least a specific dollar amount ($170 in 2021) to be eligible for a Level 3 appeal.
Review by the Medicare Appeals Council. If you disagree with the administrative law judge’s ruling, you can request a review by the Medicare Appeals Council.
Review by a federal district court if your claim is worth at least a certain amount of money. For 2021, that amount is $1,670.
Appeals for Advantage and Part D claims follow a slightly different process at levels 1 and 2. Your plan documents and benefit statements will guide you through the procedure.
How soon does a hospital have to reply to a Medicare grievance complaint?
If you are discharged from the hospital before you believe you are ready, you can file an expedited appeal. You should have received at least one Important Message from Medicare during your hospital stay. The message includes instructions for appealing if the hospital discharges you, and you disagree with the decision.
You must file the appeal with the Quality Improvement Organization by midnight on the day of discharge. The hospital must provide records to explain why treatment is ending, and the QIO will decide within 24 hours.
If your appeal is unsuccessful, you have until noon of the day following your denial to file a petition with the Qualified Independent Contractor. You can expect a decision within 72 hours.
How many days do you have to file a grievance for Medicare?
You have 120 days from the date you receive your MSN to file a Medicare appeal. However, if you have Medicare Advantage, you must appeal within 60 days of the coverage determination. Grievances are a different process. They address problems with the quality of care, not Medicare’s payment for it. Grievances must be filed within 60 days of an incident.
How to Win a Medicare Appeal for Skilled Nursing
If you are an inpatient at a hospital for at least three days, Medicare will cover a limited number of days of rehab in a skilled nursing facility. However, sometimes Medicare cuts off coverage before you feel ready to go home.
To prepare an appeal, find out why Medicare denied coverage. Focus on explaining why this reasoning was incorrect. If Medicare denies coverage because you didn’t go to physical therapy, you could submit medical records confirming that you were too sick.
Always stick to the facts and offer supporting documents whenever you can. It’s also a good idea to reach out to the agent that sold you your Supplement or Advantage coverage. Some companies, such as EIP, will help clients navigate the appeals process.
How to Appeal Medicare Part B Penalty Appeal
If you don’t enroll in Part B when you are first eligible, Medicare may assess a late enrollment penalty when you do sign up. You can appeal the penalty if you believe Medicare made a mistake. The penalty notice describes the appeal procedure. However, you must continue paying the penalty while your appeal is pending.
What is the Part D Patient Rescue Appeal
Also known as a continuation of medication appeal, a patient rescue appeal will benefit you if your Prior Authorization or Step Therapy requirements are pending. The continuity of care will get you the medication you need, even if it’s only a small refill until the insurance company works out the paperwork.
How can a Medicare contractor help you with an appeal?
Medicare contractors can help with claims and appeals. If you request a redetermination, a new contractor will view the appeal.
How to appoint a representative to file an appeal?
You’ll need to fill out the “Appointment of representative” form. You’ll send the request to the Medicare contractor or the health plan that handles your claims.
How to Get Help Filing a Medicare Appeal
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 advise 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 quickly. If you want to learn more about our policies or our Client Service Team, please contact us at the phone number above. You can also compare rates with our online rate form!
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