The U.S. Centers for Medicare and Medicaid Services (CMS) provide valuable health insurance coverage for millions of Americans, but that doesn’t mean their decisions are always correct. You have a legal right to file an appeal if you disagree with a recent payment or coverage decision regarding your Medicare plan.
First, though, you should familiarize yourself with the process to increase your chances of a favorable outcome. In this post, our specialists from The Modern Medicare Agency will explain how to appeal Medicare denial claims and outline the necessary steps you’ll need to take.
If you haven’t started the plan enrollment process, we invite you to call us. Our licensed agents will help you determine which Medicare plans from The Modern Medicare Agency best suit your needs and offer the comprehensive coverage you want.
What Is a Medicare Appeal Regarding Health Care Service Denial?
Should beneficiaries disagree with a specific payment or coverage decision from Medicare, they have a legal right to file an appeal. For example, you may begin the appeals process if Medicare or your plan denied coverage or payment for:
- A request for a drug, item, supply, or health care service you believe Medicare should cover (pre-service appeal)
- A request to modify out-of-pocket expenses for a drug, item, supply, or health care service.
- A request for Medicare to pay for a drug, supply, health service, or item you already received (post-service appeal)
Additional circumstances are also eligible for an appeal, including:
- If Medicare or your plan denies payment or refuses to cover care for some or all of a drug, item, supply, or health care service you believe you still need.
- If you are in a drug management program and Medicare restricts access or denies coverage for drugs with a high risk of abuse, like benzodiazepines or opioids.
In addition, you may request an expedited appeal if you have a service discharge from a home health plan, skilled nursing facility, comprehensive outpatient rehabilitation facility, or hospice.
Levels of the Medicare Appeals Process
Under Original Medicare, you can file your appeal through five separate levels. Each level of appeal consists of an independent review of your request, involving consideration of factors like quality of care, medical necessity, mitigating circumstances, etc.
- Level One: A Medicare Administrative Contractor reviews your appeal.
- Level Two: A qualified independent contractor reviews your appeal.
- Level Three: The Office of Medicare Hearings and Appeals (OMHA) reviews your appeal.
- Level Four: The Medicare Appeals Council reviews your appeal.
- Level Five: The federal district court reviews your appeal.
How To File an Original Medicare Appeal
After you receive a denial notice for Medicare Part A or Part B services, you can begin the appeal process. Be sure to thoroughly examine your plan materials before writing your requests.
First, submit a written request asking CMS to reconsider its original decision. You can do so by filing a Redetermination Request form or writing a letter. Check your Medicare Summary Notice for the correct address. If you choose to send a letter, it should contain the following information:
- Your Medicare number
- Your name and current address
- Any services or items you want Medicare to pay for (including the date of said services or items)
- A thorough explanation of why Medicare should cover or pay for your claim
- The name of any representative helping you file the appeal
Next, you should receive an answer for your denial appeal in a timely manner, usually under two months. If your request doesn’t make it through the first level of appeal and receives a denial notice, you can continue appealing to the next level.
The third level requires you to submit another appeal within 180 days of the date on your redetermination notice. You can complete this step in writing or by filling out the Medicare Reconsideration Request form.
Next, you’ll receive a response within 60 days. If you still receive a denial, your claim will then go to the OMHA. After that, you’ll receive notice from a qualified independent contractor.
The OMHA will send a decision within 90 to 180 days. Upon denial, you may continue your appeal by asking the Medicare Appeals Council to review your case. However, there’s a 60-day deadline to send a Request for Review of Administrative Law Judge Decision or written letter.
The last recourse in your appeal rights is to present your case to a judge in a federal district court. If the Council cannot reach a decision, you’ll have 60 days to file a claim in federal court.
Medicare Advantage Plan and Part D Appeals Process
Both the Medicare Advantage plan (Part C) and the Medicare Part D prescription drug plan appeals are different from Part A and B but have a separate timeframe. These plans supplementing A and B coverage are only available from private insurers.
If CMS has denied you prescription drug coverage, doctor services, payment, or other Medicare claims, you can begin a similar five-step appeal.
- Level One: Reconsideration request (60 days)
- Level Two: Independent review entity (10 0days)
- Level Three: OMHA review – Form OMHA 100, Form OMHA 104, or written request (60 days)
- Level Four: Medicare Appeals Council – DAB-101 or written request (60 days)
- Level Five: Federal Court (60 days)
Quick Tips to Facilitate Your Appeal
Consider these quick tips that may help your appeal:
- Assign a representative
- Carefully examine your denial letters
- Send documents via certified mail
- Ask your doctor or healthcare provider for help preparing your appeal
- Keep meticulous records of your progress and case timeline
- Consider investing in legal services from an attorney
Call Us at The Modern Medicare Agency Today
As you can see, knowing how to appeal Medicare denial claims is vital. At The Modern Medicare Agency, we help millions of Americans just like you obtain the health care coverage they need with our comprehensive policies.
Whether you want assistance with Medicare open enrollment or determining which coverage types will suit your needs best, our specialists are ready to help you. Call us at The Modern Medicare Agency at (800) 219-0453 for a free consultation.