Original Medicare, Medicare Advantage, and Part D plans can deny coverage for a health service or medication. However, individuals have the legal right to appeal the decision if they think it is incorrect.
A person can submit an application form with a statement, as well as some supporting evidence, outlining why they disagree with Medicare’s decision.
Medicare will then review the information and either allow or refuse the appeal.
People enrolled in Medicare have rights and protections surrounding their healthcare services. The Medicare appeals process is one of these rights, and it allows a person to appeal a Medicare decision about coverage denial or late payments, such as penalties.
The Medicare appeals process has five levels, each with a separate review process. An appeal is required at each level. If Medicare approves an appeal at the first level, the process stops. Alternatively, if Medicare denies the initial appeal, the process can go to the next level.
An individual must collect supporting documents from their doctor or healthcare provider to prove their appeal case to Medicare. They will submit these documents, along with the appeal form, to Medicare.
People have the right to appeal if they disagree with Medicare’s decision for the following reasons:
- a request for a healthcare service, supply, item, or prescription drug
- a payment request for a healthcare service, supply, item, or prescription drug already received
- a request to change the amount someone pays for a healthcare service, supply, item, or prescription drug
Medicare may deny coverage for the following reasons:
- The item, service, or prescription drug is not medically necessary.
- An individual does not meet the eligibility requirements for coverage.
- Medicare does not cover the item, service, or prescription at any time.
Monthly premium penalties
An individual can also appeal against Medicare’s penalty decisions. These include:
Late enrollment penalty
For example, Medicare charges a late enrollment penalty if a person does not enroll in original Medicare Part B or Part D when they first qualify or does not have other coverage from another source.
In the above situation, if a person had health insurance from an employer but Medicare charged a late enrollment penalty, the person can appeal that decision. Evidence to appeal will include proof of adequate coverage comparable with that of Medicare Part B or Part D.
Income-related monthly adjustment amount surcharge
Here is another example: Medicare assesses a person’s income as reported on their tax return from 2 years ago to calculate the Medicare Part B and Part D premiums. The Medicare income-related monthly adjustment amount (IRMAA) is a surcharge added to the standard premiums.
In that situation, a person would be able to appeal an IRMAA surcharge if they disagree with Medicare’s assessment.
The appeal process starts when a Medicare beneficiary receives an official written notice that Medicare denies coverage. Standard notice types include:
- Medicare Summary Notice (MSN): The MSN shows Medicare payments for covered services and items for the previous 3 months. It also indicates if Medicare denies any item or service.
- Advance Beneficiary Notice of Noncoverage (ABN): Doctors and other healthcare providers and suppliers issue this notice as an advanced warning that Medicare may not cover a service or drug.
- Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN): If someone is staying in an SNF and approaching the maximum number of covered days, the SNF issues this notice. They always give at least 2 days of notice before coverage stops.
- Fee-for-Service Advance Beneficiary Notice (FFS ABN): This notice tells someone that Medicare will charge them for a service they had or are due to receive.
- Notice of Denial of Medical Coverage (Integrated Denial Notice): Medicare Advantage plans and Medicaid issue these notices if they will not cover any part of a service.
- Hospital-Issued Notice of Noncoverage (HINN): Hospitals use this form if Medicare coverage for inpatient stays is ending.
- Notice of Medicare Non-Coverage (NOMNC): This notice is similar to the HINN, but it refers to inpatient care in an SNF, rehabilitation facility, or hospice.
When a notice is sent out, it includes information about the appeals process. However, the various Medicare parts have different methods for starting an appeal, as follows:
- Original Medicare (parts A and B): Usually, people must complete a Redetermination Request Form for an appeal against a decision involving original Medicare.
- Medicare Part D: If a person wants to appeal a Part D decision, they can check the evidence of coverage information to confirm the process. Learn more about Medicare Part D here.
- Medicare Advantage plans: Different rules apply to Medicare Advantage plans, and a person can contact their plan provider for information about appealing a decision. Learn more about Medicare Advantage plans here.
Each appeals form requires basic personal information and some details of the claim. People must include details of the service or item they are appealing and why they think Medicare’s decision is incorrect. They also need to provide supporting evidence, such as a doctor’s letters, test results, or diagnosis information.
Decision notification limits
Notifications of decision have various time limits, depending on the Medicare part. For example:
- Original Medicare (parts A and B): Medicare will provide a decision within 60 days of receipt of the appeal.
- Part D prescription drug and other health plans: There are different decision response times, including 24 hours for an expedited request, 72 hours for a standard service request, and 14 days for a payment request.
The Medicare appeals process has five levels. If someone disagrees with a decision at any level, the appeal moves to the next level of review.
At each level, Medicare sends out a decision letter, which includes details of the next steps.
These are the five review levels:
- level 1: initial review by a Medicare administrative contractor
- level 2: qualified independent contractor or independent review entity review
- level 3: Office of Medicare Hearings and Appeals review
- level 4: Medicare Appeals Council review
- level 5: judicial review by a federal district court (if the claim is more than $1,760)
People should include as much supporting information as possible with the appeal. Information from doctors, healthcare providers, or suppliers can help toward getting a favorable decision.
If waiting for a decision would affect a person’s health, they can ask for a fast appeal. An example of the need for a fast decision might be if someone is an inpatient in a hospital or SNF and they are concerned that the facility is discharging them too soon.
In that case, the person has a right to an immediate review by the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO). The notice includes contact information.
While the BFCC-QIO are reviewing the case, the hospital cannot discharge the person, and they can stay in the hospital with no charge. The BFCC-QIO have 72 hours to decide the appeal.
A person in a nursing facility or other inpatient setting will get a notice at least 2 days before the coverage ends. The BFCC-QIO have until the end of the business on the day before an individual is due to be discharged to make a decision about the appeal.
The Medicare time limits for appeals depend on the Medicare part.
For original Medicare (parts A and B), a person has 120 days from the day they received the notice to appeal.
With Medicare Advantage plans and Part D prescription drug coverage, a person has 60 days from the day they received the notice to file an appeal.
If a person decides to cancel a Medicare appeal, they should call Medicare at 800-MEDICARE (800-633-4227). They will need to provide the following information:
- their full name
- their Medicare ID number
- the date they submitted the appeal form
- details about the appeal
- the reason they are canceling the appeal
The Medicare appeals process does not have any associated costs.
People can find free help with the appeals process and any other Medicare matter at their local State Health Insurance Assistance Program.
If Medicare denies coverage of an item or service, an individual has the right to appeal the decision. People must provide proof with a claim and submit this to Medicare with an application form.
The appeals process has five levels, and each has different reviewers. The appeal will move to the next level if the review board refuses the appeal.
Typically, Medicare decides within 60 days, but people can get a fast appeal if it concerns an inpatient stay and if waiting for a decision could affect their health.