Have you ever wondered what to do when Medicare denies your claim? If Medicare denies your coverage or if Medicare refuses to pay your claim there is a process that you can follow to appeal Medicare decisions.
If you want to know more about how to do this, the exact steps of the appeal process and the difference between filing a Medicare appeal and filing a grievance, read on.
What is the Process?
The first thing you must do is get an initial determination. This will either be a determination that, yes, a service is paid for or no, it is not covered.
When Can I File a Medicare Appeal?
An initial determination may not be appealed for just any reason. The reasons that an initial determination may be appealed are:
- You need to continue a specific service or item that Medicare has covered either partially or fully in the past.
- You believe the service or item should be covered by your chosen plan.
- You were covered for the service or item in the past.
- Your claim is for a difference in the amount charged.
- For Medicare Medical Savings Account (MSA) Plans: You believe a service or item should be counted towards your deductible.
If you have one of these concerns and the initial determination denied your coverage, then you should go forward with filing a Medicare appeal.
How Do I File a Medicare Appeal?
You or a representative that you choose can file to appeal a Medicare decision asking for the initial determination to be reconsidered.
Step 1
If you have a Medicare Advantage Plan, you will receive a notice that will inform you of why they have not covered a specific requested service or item. If you don’t agree with the reason that they give then you should file an appeal.
If you have Original Medicare, when you receive your quarterly Medicare Summary Notice, if a service or item is not covered and you disagree with this decision, you can file a redetermination request.
Step 2
With a Medicare Advantage Plan, the notice that you receive will give you instructions on how to do this or you can contact your plan provider directly. You have 60 Days to ask for reconsideration. If they decide against your appeal, then you have 10 days to contact an Independent Review Entity (IRE) to have your case looked at again.
With Original Medicare, a Qualified Independent Contractor (QIC) will consider your request and you will be notified of the outcome. If you do not agree with the outcome you may want to move onto the next step in the process.
Step 3
Whether you have a Medicare Advantage Plan or Original Medicare, you will have 60 days to ask for a hearing if you dispute your Medicare appeal outcome and the amount-in-controversy is high enough to qualify. Your appeal would then be heard by an Administrative Law Judge (ALJ).
Step 4
If you do not agree with the decision of the Administrative Law Judge (ALJ) and the amount-in-controversy is high enough to qualify, then you may request that your appeal be heard by the Medicare Appeals Council Review.
Step 5
If the Medicare Appeals Council Review fails to make a decision within 90 days or if you do not agree with their decision and the amount-in-controversy is high enough to qualify, you can ask for a judicial review in Federal district court.
Tips for Medicare Appeals
- Read your Medicare plan so that you are sure you understand the process.
- Contact your primary care physician (or pharmacy) and request any information that might help you in the Medicare appeal process.
- Pay special attention to dates and time frames and never miss a hearing.
- If you are in imminent danger due to the decision, you can request a fast review and your appeal may be able to be reviewed in as little as 72 hours.
What is the Difference Between a Medicare Appeal and a Grievance?
When you ask for a Medicare appeal, you are asking for a reversal in a decision about what your plan covers. A grievance is different because you file a grievance when you are not happy with the service that is provided to you.
Your grievance (or complaint) may be with your healthcare provider, healthcare facility, your Medicare plan or a medical equipment provider.
How Do I File a Grievance?
You can call your Medicare health plan and ask to file a grievance over the phone. You can also go to the health plan website and get the form to put your grievance in writing. No matter what you choose, they will investigate the problem and notify you of the results within 30 days.
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