You have the right to file a Medicare appeal if you disagree with a decision to deny coverage of a service, prescription, and medical items or supplies. It may sound intimidating to challenge Medicare’s decision on your healthcare coverage, but in many cases it’s worth your time and effort. More than 50 percent of Medicare appeals are reversed.
When Should You File?
You can file an appeal when Medicare decides to stop paying for a drug or service it used to cover, when Medicare didn’t pay enough of the covered amount, or when Medicare refuses to pay altogether for care that should be covered. Sometimes further explanation and documenting evidence is needed to support your claim and sometimes Medicare may have simply made an error.
What You Should Do
When you receive your Medicare Summary Notice (MSN), it will list all of the services and supplies that were billed to your Medicare plan within the last three months. The MSN will show whether Medicare fully or partially denied the claim. If you want to appeal any of the decisions, you must file an appeal within 120 days of receipt of the MSN.
You can fill out a Redetermination Request Form and send it to the address listed on the MSN. You can also circle the item on your MSN that you are appealing and write a letter explaining your reasoning, then send it to the listed Medicare contractor address. You should also include a letter from your doctor that states why the service or item is medically necessary, along with any supporting medical documentation to uphold the claim.
Make sure you retain copies of all the documentation you send and be sure to include your Medicare number on all of your appeal filings.
The Five Levels of a Medicare Appeal
There are five different levels of a Medicare appeal. At the first stage, you are simply requesting a redetermination of the decision from the company that handles your Medicare plan’s claims. If the second decision doesn’t go your way, you can then appeal for a review by a qualified independent contractor (QIC).
Next, you’re entitled to a hearing before an administrative law judge, then a review by a Medicare appeals council, then a judicial review by a federal court.
If you need your claim decided quickly for health reasons, you can request a fast decision within 72 hours.
Learn About Your Coverage
When it comes to advocating for your own healthcare needs, your best defense is an in-depth knowledge of your Medicare plan and all of the services and equipment it covers. To learn more about what your current or prospective plan offers, contact My Senior Health Plan. We will help you understand your rights so you know when to file a Medicare appeal.