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Navigating the Medicare Appeal Process: A Step-by-Step Guide

How to Appeal a Medicare Claim Denial 

Medicare plays a key role in helping more than 65 million enrollees access healthcare, but sometimes, it denies claims. If Medicare denies your request for a health service you think it should cover or denied payment for a service you already received, you have a right to appeal.

Filing an appeal for a Medicare denied claim can seem daunting, but the process is more straightforward than you might think. There are five levels of appeals, and the details vary depending on which type of Medicare coverage you have. 

Why Medicare May Deny a Claim 

Both Original Medicare and Medicare Advantage may decline claims for many reasons. Some of the most common ones include

  • Medical necessity: Services are deemed unnecessary if they do not diagnose or treat the patient’s health conditions or do not meet accepted medical standards.
  • Frequency limits: Coverage for some services is capped at a certain number of days or visits per benefit period or year.
  • Non-covered benefits: Neither Medicare nor Medicare Advantage covers every health service.
  • Lack of prior authorization: Some Medicare plans require members to get approval before receiving a covered service.
  • Coding Issues: A Medicare code refers to a specific alphanumeric identifier used to classify and describe medical diagnoses, procedures, treatments, services, and supplies. Medicare may deny a claim if there were coding issues during any of those processes.
  • Coordination of Benefits: Medicare may deny a claim due to coordination of benefits if the patient has other primary insurance coverage that should have been billed first, but the claim was instead submitted to Medicare as the primary payer. Additionally, if the coordination of benefits information provided on the claim is incomplete or inaccurate, it can lead to claim denial by Medicare.

What Can You Appeal? 

Medicare beneficiaries can choose to appeal many decisions made by their plan. The three main kinds of appeals are denied requests for:

  • Services you think should be covered: For example, if Medicare or your plan refuses to approve the durable medical items you think you need, you can file an appeal.
  • Payments for services you already received: For instance, if Medicare or your plan deems a recent hospital stay unnecessary and denies the claim, you may be able to demonstrate that it was necessary.
  • Changes to the amounts you pay for covered services: For example, your plan could deny your request to cover a drug at a lower level of cost sharing.

Things to Keep In Mind For Appealing a Denied Claim

If you received a denial notice and plan to begin the Medicare appeal process, there are some things to keep in mind as you consider an appeal. 

Your Rights as a Medicare Beneficiary to Appeal 

People with Medicare have certain rights and protections that make their health coverage more fair. One of these protections is the right to appeal if Medicare or a Medicare plan makes a coverage or payment decision they disagree with. 

Beneficiaries also have the right to a fast appeal if they think Medicare-covered services in certain facilities are ending too soon. This includes hospitals and skilled nursing facilities.

Time Limitations to Appeals 

The right to file an appeal is not open-ended. Beneficiaries must submit their request within a certain number of days, and the time limit for initial appeals varies depending on the type of coverage.

People with Original Medicare must file their appeal within 120 days of receiving their Medicare Summary Notice. For both Medicare Advantage and Part D plans, the appeal must be filed within 60 days from the date of the plan’s denial notice. 

Have Necessary Documents and Information On Hand 

Before filing the request for an appeal, gather information or documentation that could help your claim get approved. This includes billing statements, medical records, a letter from your doctor, and anything else you think supports your case. 

Prepare a timeline of the situation, including the dates you received services and the providers who were involved. Be as specific as possible to make it easier for Medicare or your plan to understand what happened.

Understand the Medicare Appeals Levels 

By law, there are five levels of the Medicare appeals process. People with Medicare can request a first-level appeal if they disagree with a coverage or payment decision. If they disagree with the results of this initial appeal, they have the option to file for a second level of appeal.

Some beneficiaries can continue to the third, fourth, or fifth levels of the appeals process. This depends on the amounts of Medicare denied claims.

Level 1: Redetermination 

In the first level of Medicare appeals, a Medicare Administrative Contractor (MAC) takes a second look at the case and determines if the denial was appropriate. MACs are private health insurers that contract with Medicare. The people who review level one appeals are not the same people who reviewed the initial claim.

Generally, the MAC decides within 60 days of getting the appeal request. Beneficiaries who disagree with the MAC’s decision have a right to move to the second level of the appeals process.

Level 2: Reconsideration 

People who are not satisfied with the results of their first appeal have 180 days to request a reconsideration. This second appeal is processed by a Qualified Independent Contractor (QIC), an organization not involved in the first level of the appeal.

At this point, beneficiaries have the opportunity to submit any additional documentation that supports their appeal. New documentation may not be accepted in later appeals. Once the QIC receives the request, it makes a decision within 60 days.

Level 3: Administrative Law Judge Hearing 

The third level of the Medicare appeals process is available if the disputed claim amount is more than $180 in 2023. Beneficiaries who are eligible to move to this level have 60 days to request a hearing from the Office of Medicare Hearings and Appeals (OMHA). 

The hearing is conducted by an Administrative Law Judge, typically via telephone. Beneficiaries who prefer not to attend a hearing can request an attorney adjudicator review their case. Level three decisions take up to 90 days.

Level 4: Medicare Appeals Council Review 

Beneficiaries who disagree with the Administrative Law Judge’s decision have 60 days to request a review by the Medicare Appeals Council. This Council is separate from both Medicare and OMHA.

The Council examines the facts of the case and the decisions made in earlier levels of appeals, then provides its own impartial decision within 90 days. Beneficiaries who disagree with this decision may have the opportunity to appeal again.

Level 5: Federal District Court Judicial Review 

The last level of Medicare appeals is judicial review in a federal district court. This appeal level is reserved for disputes with relatively high dollar values. For 2023, the disputed claim amount must be at least $1,850.

Beneficiaries who meet this requirement have 60 days to file a civil action in their local Federal district court. This is a formal court proceeding, so working with an experienced Medicare attorney is a good idea. The court’s decision is binding.

How to Appeal Original Medicare Claim Denial 

Original Medicare (Part A and Part B) is the traditional health insurance program run by the federal government. Here’s how to start the Original Medicare appeal process.

1. Review Your Medicare Summary Notice (MSN) 

A Medicare Summary Notice is a document that outlines all the Medicare Part A, and B covered services a beneficiary received recently. Medicare sends these notices in the mail every three months.

The MSN shows each service your providers billed to Medicare and the amount the providers charged. It shows whether or not each service was approved and, if so, the amount Medicare paid. 

If Medicare denies a claim, the MSN states the reason for the denial. It also provides instructions and deadlines for filing an appeal. 

2. Complete the Form on Your MSN 

The last page of the MSN is an appeals form. Carefully follow the step-by-step directions on this form if you want to appeal, and remember to:

  • Circle the claims you want to appeal.
  • Explain in writing why you disagree.
  • Attach any documents that support your appeal.
  • Write your Medicare number on every page.
  • Keep a copy of the form for your records.

3. Await a Decision on Your Appeal 

Generally, appeals decisions take up to 60 days from the date the Medicare Administrative Contractor receives the appeal requests. You’ll be notified of the decision in a letter or your next MSN. 

4. Move to the Next Level If Needed 

Beneficiaries who disagree with the result of their first appeal can request a reconsideration. Moving to the next step of the process means a Qualified Independent Contractor will review the case.

How to Appeal Medicare Advantage Claim Denial 

Medicare Advantage is a private plan alternative to Original Medicare. It covers the same Part A and B services as the traditional program, but it’s administered by private insurance companies.

Medicare Advantage is still Medicare, so people who get coverage through these plans have the same appeal rights as other Medicare beneficiaries. However, in these plans, the Medicare appeal process works differently. 

1. Request Organization Determination From Your Insurer 

Medicare Advantage enrollees have the right to ask whether or not their plan will cover a certain item or service. The plan’s decision to approve or decline the request is known as an organization determination. 

If a health plan denies an enrollee’s request, it will provide an initial denial notice called an adverse organization determination. Plan members who disagree with this denial can appeal.

2. Follow Appeals Process Instructions From Organization Determination Letter 

The adverse organization determination provides details about why the plan denied the request. It should also provide information on how to start the appeals process. In Medicare Advantage, the first level of appeal is a reconsideration by the plan. 

Plans typically require enrollees to submit a written request for reconsideration, but some insurers accept requests via phone. In either case, be prepared to provide your:

  • Medicare number
  • Plan member number
  • Reasons for filing an appeal
  • Supporting documentation

3. Await a Decision on Your Appeal 

After a Medicare Advantage Plan receives a request for reconsideration, it must notify enrollees of its decision within the following time frames:

  • Expedited requests: 72 hours
  • Standard requests: 30 days
  • Payment requests: 60 days

4. Move to the Next Level If Needed 

In Medicare Advantage, denied reconsiderations are automatically moved to the next stage of the appeals process. The plan submits its files to a third-party company that contracts with Medicare, known as the Part C Independent Review Entity. This company determines if the plan’s denial was correct.

Plan members who disagree with the results of the second appeal may move to the next level if necessary.

How to Appeal Medicare Part D Claim Denial 

Medicare Part D is an optional prescription drug benefit for people with Medicare. Insurance companies sell standalone Part D plans designed to work with Original Medicare and some types of Medicare Advantage Plans

In some cases, Part D plans deny coverage for the drugs people with Medicare take. Plan members have a right to appeal, but since private companies administer these plans, the appeal process is different than in Original Medicare.

1. Request Coverage Determination From Your Insurer 

A coverage determination is a decision made by a Part D plan. Enrollees request coverage determinations for many reasons, including asking their plan to pay for a drug or to provide a formulary exemption or prior authorization. Plans typically need to respond within 72 hours, though this varies depending on the type of request.

2. Follow Appeals Process Instructions From the Coverage Determination Letter 

If your Part D plan denies your request, the coverage determination letter will explain the reason for the denial. If you disagree with the denial, follow the instructions in the letter to request a redetermination.

Part D plans accept written and, in some cases, verbal requests for redetermination. Carefully follow the plan’s instructions and be prepared to provide the following:

  • Your Member ID number
  • The name of the drug you’re requesting
  • Contact information for the prescriber
  • Your reasons for filing an appeal

3. Await a Decision on Your Appeal 

Part D plans review the appeal and respond with a letter called a Redetermination Notice. How long it takes to get this decision varies depending on the type of request.

  • Expedited requests: 24 hours
  • Standard requests for service benefits: 72 hours
  • Standard requests for payment redeterminations: 14 days

4. Move to the Next Level If Needed 

Plan members who disagree with the redetermination have 60 days to move to the next level of appeals. The second level appeal is a reconsideration of the case by an Independent Review Entity. This is an outside organization that has a contract to review Medicare appeals.

Tips for a Successful Appeal 

The appeals process can be somewhat daunting, but it’s important to stay the course and persevere if you feel you have a legitimate complaint. To increase your chances of getting the result you want from Medicare or your plan, keep the following tips in mind:

  • Be persistent: Medicare beneficiaries have a right to up to 5 levels of appeals. If you disagree with a decision you receive, move to the next level.
  • Seek professional assistance: State Health Insurance Assistance Programs help beneficiaries file appeals. You can also seek advice from an attorney, financial advisor, doctor, or anyone else with experience navigating appeals.
  • Send clear communications: To help Medicare or your plan understand your requests, be sure to clearly state the facts of your case and why you think the denial should be overturned.

Your Options If Your Claim Is Still Denied 

There are other steps to consider if you’ve exhausted your appeals and your claim is still denied. If you have other health insurance, find out if the other plan will help pay the portion that Medicare refused to cover. If you think the Medicare claims denial was unfair, consider filing a formal complaint with Medicare or your state’s Department of Insurance.

Putting It All Together 

Whether you get your Medicare benefits through Original Medicare or a Medicare Advantage Plan, denied claims are a possibility. However, getting a denial notice does not necessarily mean that Medicare or your plan will not pay for your care. Medicare beneficiaries have the right to as many as five levels of appeals. 

If you plan to file an appeal, mark the applicable filing deadlines on your calendar. Carefully follow Medicare’s appeal process instructions, and be sure to ask your healthcare provider for any medical documentation that may support your request. 

Frequently Asked Questions 

What is the timeframe for filing a Medicare appeal?

The timeframe for filing a Medicare appeal varies depending on how you get your Medicare coverage. In Original Medicare, beneficiaries have 120 days to file a Level One appeal. In Medicare Advantage, Level One appeals must be filed within 60 days.

Can I keep using my coverage while my appeal is being processed?

Exercising your right to file a Medicare appeal does not affect your coverage. While your appeal is being processed, you can continue using your Original Medicare, Medicare Advantage, or Part D plan as normal.

Do I need an attorney to file an appeal?

No, it’s not mandatory to hire an attorney during the Medicare appeals process. However, working with an experienced Medicare attorney can be helpful, especially in the later stages of the appeals process. If you cannot afford an attorney, contact legal aid societies or your state bar association.

What if my claim is only partially denied?

If your Medicare claim was only partially denied, you still have a right to appeal. Follow the Medicare appeals process to ask Medicare or your plan to reconsider the partial denial.

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