Medicare enrollees that received a coverage denial will be notified via either a Medicare Summary Notice (MSN) or if you are enrolled in a Medicare Advantage plan you will receive a Explanation of Benefits (EOB). When you do not agree with Medicare’s determination concerning the coverage of a claim or service, you have the right to appeal the decision.
A Medicare appeal is an official request for the review of a decision concerning a healthcare claim, where you ask your Original Medicare, Part D, or Medicare Advantage plan to reconsider their determination.
Your appeal can pertain to denials for medication, an in-office procedure, a piece of medical equipment, or even a portion of your hospital stay. As long as you have Medicare Part A, Part B, Part D, or an Advantage plan, you have the right to appeal the denial. Just be sure to follow the Medicare appeal process.
What Is the Appeal Process for Medicare?
The process can be broken down into 5 steps:
- Review your Medicare Summary Notice (MSN). The summary notice is the paperwork that you receive once every quarter, explaining the denial or payment of your medical claims.
- Contact Medicare if you don’t understand the reason for the denial. Call 1-800-MEDICARE or your Advantage or drug coverage provider if you need more information about the denial.
- Complete a Redetermination Request form. To appeal your claim decision, you will need to complete and submit a Medicare form called a Redetermination Request.
- Locate the insurance company name and address. Review the last page of your Medicare summary notice to locate the name and address of the company that should handle your appeal.
- Mail your Redetermination Request form. Submit the Redetermination Request and any supporting documentation to the designated address.
Tips for Handling Documents
If you do not have a Redetermination Request form available, you can submit an appeal request by sending your name, address, Medicare number, and a copy of your summary notice to the address on the last page of your MSN. Be sure to circle the denials that you would like to appeal. Also, include the reasons that you believe that each denial is in error. If you have any supporting documentation, such as physicians’ notes or records, they may be able to help in the appeal of your claim. Moreover, be sure that your Medicare Number is written on each document that you send with your appeal. Do not send original documents and make copies of all the appeal documentation, in case you need to access or reuse the information later. It would be wise to consider sending the appeal via certified mail or delivery confirmation.
The Five Levels of Appeal
There are five levels of appeal with Medicare. If your first appeal is unsuccessful, you may be able to appeal the denial again. The instructions for the next appeal are included in each decision letter.
At each appeal level, your claim is reviewed by a different entity. Here are a few details about each level of appeal:
- Level 1- The appeals department of your plan’s insurer. You send your original appeal to the insurance company that processes your Medicare, Medicare Advantage, or Part D claims.
- Level 2- An independent contractor. Once your original appeal is denied, a Qualified Independent Contractor—one that did not process the original claim— can reconsider the decision.
- Level 3- The Office of Medicare Hearings. At the third level of appeal, you will present information to support your case to the Office of Medicare Hearings. An administrative law judge reviews the information presented and decides whether your claim should be paid. Currently (in 2022), at this level, the dollar amount of the disputed charge must be at least $180.
- Level 4- The Medicare Appeals Council. If the law judge upholds the denial, you may submit the appeal to the Medicare Appeals Council.
- Level 5- A federal district court. If you do not agree with the council’s decision, you may request that a federal district court review the claim. However, you may only submit a request at this level if your claim meets the minimum monetary threshold, which is $1,760 for 2022.
How Much Time Do You Have to Request an Appeal?
With Original Medicare, you have 120 days after the receipt of your MSN to file an appeal. If you are appealing a Medicare Advantage decision, you have 60 days from the date of your Explanation of Benefits to submit a request.
If you are unable to file your appeal within the designated time allotment, you may contact your insurer to ask for a good cause extension.
A good cause extension is granted on an individual basis. A few examples of acceptable reasons for an extension include:
- Receiving incorrect information from a Medicare representative about your denied claim.
- Receiving an MSN notice late because it went to an incorrect address.
- Experiencing communication problems because the beneficiary who is appealing doesn’t speak English or has literacy problems.
- Being too ill to submit the appeal.
When sending information explaining the reason for filing a late appeal, include any documentation that supports your explanation, such as a doctor’s note for a serious illness.
Is The Appeal Process Different for Medicare Advantage?
With Medicare Advantage, the process to appeal a denied claim is almost the same as it is for Medicare. However, you submit your appeal request to your plan’s insurer. Instructions are on the explanation of benefits that you receive to show the claim denial.
How Do You Appeal a Denied or Incorrect Prescription Drug Claim?
If you have Medicare Part D, which covers the cost of prescription drugs, you may decide to appeal the denial of the drug charge. Like Medicare Advantage appeals, Part D appeals are sent to the plan’s insurance company.
In addition to denied claims, you may encounter instances where Medicare Part D pays for a drug that you did not receive or that you no longer take. The process is the same as it is for the appeal of a claim denial.
How Long Does Medicare Take to Answer an Appeal?
After filing an appeal with Medicare, you can expect to receive a determination letter within around 60 days. If you have a Part D plan, you can expect a decision within 72 hours. Beneficiaries with Medicare Advantage should receive a response within about 14 days.
In some cases, such as an appeal involving a disputed hospital discharge or the discontinuation of Medicare coverage for one of your current services, you may be able to submit an expedited appeal.
If You Are Disputing a Hospital Discharge, How Quickly Must the Hospital Respond to Your Expedited Appeal?
If you feel that you are being sent home from the hospital before you are ready, you can submit an expedited appeal. During your hospital stay, Medicare will send you a message that includes the instructions for filing an expedited appeal if you disagree with the hospital’s timing of your discharge and feel that your stay should be longer.
Your appeal must be submitted to the Quality Improvement Organization (QIO) before midnight of your discharge day. The hospital is required to respond with records that explain the reason for the timing of your discharge. After reviewing the information from the hospital, the QIO will make a decision within 24 hours.
If the Quality Improvement Organization denies your appeal and you would like the discharge date reviewed again, you can submit a petition to a quality independent contractor. The contractor will issue a decision within 72 hours.
What Happens if Your Appeal Is Approved?
If your appeal is approved, Original Medicare, Medicare Advantage, or Medicare Part D will cover your claim for the Medicare-approved amount.
Is a Grievance Different than an Appeal?
A grievance is not the same as an appeal. It is not filed because there is a problem with Medicare’s payment of your services. Instead, the grievance addresses issues with the quality of the health care services that you received. If you have a concern about your quality of care, you have 60 days from the time of the service to file a grievance.