| Tue, Feb 12, 2013 @ 09:00 AM

How to Appeal a Medicare Decision

Posted by Medicare Made Clear

medicare appeal informationAn appeal is the action you can take if you disagree with a coverage or payment decision by Medicare or your Medicare plan. That decision can be made by Medicare or by the private Medicare-approved health plan that administers your Medicare Advantage (MA/MAPD) plan, prescription drug plan (PDP) or special needs plan (SNP).

When can I appeal a payment or coverage decision?

You can file an appeal if Medicare or your plan denies one of the following:

  • Your request for a health care service, supply, item or prescription that you think you should be able to get.
  • Your request for payment for health care service, supply, item or a prescription drug you already got.
  • Your request to change the amount you must pay for a health care service, supply, item, or prescription drug.

You can also appeal if Medicare or your plan stops providing or paying for all or part of an item or service you think you still need.

What happens if I decide to file an appeal?

If you decide to appeal, first ask your doctor, health care provider or supplier for any information that may help your case. See your plan materials, or contact your plan for details about your appeal rights. Medicare and all companies that provide Medicare plans are required to help you file an appeal.

The appeals process for all types of Medicare plans has five levels. At each level, a decision about your appeal is made and communicated to you in a letter. If you disagree with the decision made at any level of the process, you can generally go to the next level. At each level, you’ll be given instructions in the decision letter on how to move to the next level of appeal.

What’s the first step of filing an appeal?

Although we won’t go through all five steps of an appeal process, we can describe the first step. How you file an appeal depends on the type of Medicare coverage you have. But no matter what type of Medicare plan you have, at any step of the appeals process, you can—and may want to—ask your doctor, health care provider or supplier for any information that may help your case, or other help.

Original Medicare

If you’re on Original Medicare, then every three months you’re mailed a Medicare Summary Notice, or “MSN.” An MSN shows all services or supplies that health care providers and suppliers billed to Medicare for your care during the three-month period. It shows what Medicare paid, and what you may owe the provider. You can also view your MSNs electronically on MyMedicare.gov.

Your first step is to find the MSN that shows the service or supply you’re appealing. You then have two options to file the appeal:

1. Fill out a Redetermination Request Form (PDF). Send it to the Medicare contractor at the address listed in the “Appeals Information” section of your MSN. Or, you can…

2. Follow the instructions on the back of your MSN, and send the request for an appeal without the Redetermination Request Form. You provide the same types of information as what’s asked for on the form, and send it to the Medicare contractor listed.

Generally, you get a decision from your Medicare contractor within 60 days after they get your request. The decision is called a “Medicare Redetermination Notice,” and it can come as a separate notice or as part of your MSN.

Medicare Advantage Plan (Part C)

You have the right to ask the company that administers your Medicare Advantage plan to pay for, or cover, health care services or items you believe should be covered. This request for services or supplies is called an “organization determination.” You can either ask for a determination yourself, or have your doctor or someone representing you ask for one.

Organization determinations typically take 14 days. If you or your doctor thinks your health could be harmed by waiting that long, you can ask for an “expedited” or fast determination. Then your health plan has 72 hours to give you a decision.

Your plan can approve your request, or partially or fully deny it. Your plan will send you a written notice explaining why, and give you information on how to file an appeal. This process may vary depending on your plan, so follow the instructions provided. However, regardless of your plan, you are allowed to ask for a copy of your file containing medical and other case information.

Medicare Prescription Drug Plan (Part D)

Appealing a decision for a Part D plan typically means working with your plan to get coverage for a prescription drug that you feel you need. As with a Medicare Advantage plan, this usually involves either you or your doctor (or representative) working directly with the company that administers your Part D plan.

Prescription drug coverage relates primarily to your plan’s formulary, or drug list. For more information, see the previous Medicare Made Clear blog post Medicare won’t cover a prescription I need—what now?.

Medicare Special Needs Plan (SNP)

Your Medicare SNP needs to tell you in writing how to file an appeal. After you file an appeal, the plan reviews its original decision. If your plan doesn’t decide in your favor, the appeal is reviewed by an independent organization that works for Medicare, not for the plan.

For more information, contact the Medicare helpline 24 hours a day, seven days a week at 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048. If you have questions about Medicare Made Clear, call 1-877-619-5582, TTY 711, 8 a.m. – 8 p.m. local time, seven days a week.

Resources:

MyMedicare.gov—Medicare’s site to access information on your health care services and benefits, if you have Original Medicare

Medicare Costs and Health Coverage Overview—More information from MedicareMadeClear.com on Medicare coverage

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