A person may appeal when Medicare makes a decision that denies coverage of any service. They may have a better chance of winning an appeal if they gather and include supporting information from a doctor or healthcare provider.
The appeal process involves five levels. If an individual does not win the first level, they may move on to the second.
People may file an appeal for several reasons, including when Medicare, a health plan, or drug plan makes a decision that results in denial of a request for any of the following:
- to cover or pay for a piece of durable medical equipment (DME), healthcare service, or medication
- to change the fee that an individual must pay for DME, healthcare service, or medication
A person may also appeal if the decision by Medicare, a health plan, or a drug plan stops payment for all or part of DME, healthcare service, or medication.
The categories from the above examples are defined as follows:
- DME: Includes items such as a hospital bed or cane.
- Healthcare service: Includes doctor visits, lab tests, vaccinations, and emergency care when traveling abroad.
An additional reason for appealing is if a drug management program decides to limit access to a frequently abused drug, such as an opioid painkiller.
If a person believes their Medicare-covered services are ending too soon, they can ask for a fast appeal. This appeal covers categories that include services from a home health agency, a hospital, a skilled nursing facility, a comprehensive outpatient rehabilitation facility, or a hospice.
People may refer to a fast appeal filing as an immediate or expedited appeal.
Original Medicare includes Part A for hospitalization insurance and Part B for medical insurance.
A person enrolled in original Medicare — parts A and B — gets a Medicare Summary Notice (MSN) form every 3 months. The MSN lists the services or items that providers billed to Medicare and the amount Medicare paid for each.
If a person disagrees with the information on the MSN, and decides to file an appeal for a denied request for coverage, Medicare expects them to do so by the date shown on the form.
However, a person who misses the deadline but can show good cause for missing the due date may still file an appeal. Good cause may include:
- circumstances beyond a person’s control, such as illness or injury
- delays from efforts to get supporting evidence
- a death or serious illness in a family
How to file
To file an appeal against an original Medicare decision, a person can complete a Redetermination Request Form and mail it to the company listed in the Appeals Information part of the MSN.
Another method is to mail a written request to the company with the following information:
- the individual’s name, address, and Medicare number
- the specific service or item, along with the date, in which someone is requesting the redetermination
- an explanation of why the person is requesting coverage
- any supporting information that may help the case
If a person believes their health may be at risk if they have to wait for a decision, they can file a fast appeal. In these cases, and if the fast appeal filing is accepted, a person will get a decision within 72 hours.
In all other cases, a person is usually informed of the decision within 60 days of the appeal date. If Medicare decides to cover the service, it will appear on the individual’s next MSN.
Medicare Advantage is the alternative to original Medicare and provides at least the same coverage as original Medicare parts A and B. Advantage plans may also include prescription drug coverage and extra benefits such as dental care.
How to file
If someone with an Advantage plan wishes to file an appeal, they may follow the directions in their initial denial notice to start the process. The deadline for filing is 60 days from the denial date. They should include the same information required for an original Medicare appeal.
If a person believes their health may be at risk if they have to wait for a decision, they can file a fast appeal. If the fast appeal filing is accepted, a person will get a decision within 72 hours.
The response time depends on the type of request:
Medicare Part D is prescription drug coverage offered by private insurance companies to people enrolled in original Medicare. Reasons for appealing a Part D decision include:
- to get reimbursement for medication already purchased
- to get additional prescription drug benefits
How to file
To file, the person or the individual who prescribes the medication can choose to write a letter, or complete a Model Coverage Determination Request form, or call the plan.
If a person believes their health may be at risk if they have to wait for a decision, they can file a fast appeal. If this appeal filing is accepted, a person will get a decision within 24 hours.
As with Advantage plans, the response time depends on the type of request:
- within 3 days for a standard request
- within 14 days for a payment request
- within 24 hours for a fast request
A person may appeal against decisions from two additional programs. The programs are as below:
- Programs of All-inclusive Care for the Elderly (PACE): The PACE appeals process is different from the Medicare appeals procedure. A person with PACE can contact the organization for details on how to appeal.
- Special Needs Plan (SNP): These plans are a type of Medicare Advantage, but their appeals process differs from other Advantage plans. If an SNP declines an appeal, an independent organization that works for Medicare can review the decision.
In filing an appeal, a person may benefit from gathering information to support their case. This information is generally available from a person’s doctor, prescribed drugs supplier, or other healthcare providers.
To prevent lost documents, people can write their Medicare number on each one they include in an appeal request. It may also be helpful for them to keep copies of everything they submit in an appeal.
There are five levels in the appeal process, so if someone disagrees with a decision, they may go on to the next level. The decision at each level includes instructions on proceeding to the next level, up to the fifth and final level.
A person may appeal a Medicare decision if it denies coverage of a service. Supporting information from a doctor or other healthcare provider may help a person win an appeal. The appeals process has five levels.
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