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Appealing a Medicare Claim Decision

Why, when and how to challenge a denial of benefits

Filing an initial appeal for Medicare Part A or B

 

  • File your appeal within 120 days of receiving the Medicare Summary Notice (MSN) that lists the denied claim.

  • Circle the item on your MSN that you are appealing and clearly explain why you think Medicare’s decision is wrong. You can write on the MSN or attach a separate page.

  • Include additional information that supports your appeal. You may want to ask your doctor, health care provider or health equipment supplier for help in providing information that could assist in your case.

  • Carefully read the specific instructions that appear on your MSN about how to file your appeal. (Don’t forget to sign your name and include your telephone number.)

  • Make copies for your records of everything you are submitting.

  • Send the MSN and any additional information to the address listed at the bottom on the last page of your MSN. You can also use the Medicare Redetermination Form (20027) for this step. If you can’t download the form, call 800-MEDICARE (800-633-4227) to request a copy by mail.


The process for appealing a Part A or B claim has several steps

  1. The first level of appeal, described above, is called a “redetermination.”

  2. If your concerns aren’t resolved to your satisfaction at this level, you can file an appeal form with Medicare to advance your request to the second “reconsideration” level in which an independent review organization, referred to as the “qualified independent contractor,” assesses your appeal.

  3. The third level of appeal is before an administrative law judge (ALJ). If you reach this level of the appeals process, you will likely want to be represented by an attorney. Although such third-level appeals usually take place in a conference room and not a courtroom, briefs are filed, evidence is presented and witnesses are called. If the appeal is denied at the third level, it can still be presented to the Medicare Appeals Council, a department within the U.S. Department of Health and Human Services.

  4. The final level of appeal is to the federal courts. You generally have 60 days to file appeals before an ALJ, the Medicare Appeals Council and to federal court.

Next: Appealing a Medicare Advantage (Part C) claim decision. >>

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