If you disagree with a decision about one of your Medicare claims, you have the right to challenge that decision and file an appeal.
Situations in which you can appeal include:
- Denials for health care services, supplies or prescriptions that you have already received. For example: During a medical visit your doctor conducts a test. When the doctor submits a claim to be reimbursed for that test, Medicare determines it was not medically necessary and denies payment of the claim.
- Denials of a request you or your doctor made for a health care service, supply or prescription. For example: Medicare determines that a wheelchair is not medically necessary for your condition.
- Denials of a request you and your doctor have made to change the price you pay for a prescription drug. For example: Your Medicare Part D drug plan rejects your doctor’s recommendation that you receive a discount on an expensive medication because the available lower-cost drugs are not effective for your condition.
The time limits and requirements for filing an appeal vary depending on which part of Medicare (A, B, C or D) you are appealing.
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
- The first level of appeal, described above, is called a “redetermination.”
- 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.
- 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.
- 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.
Filing an initial appeal if you have a Medicare Advantage (or Part C) health plan
Medicare Advantage plans, which are administered by private insurance companies, are required by Medicare to have an appeals process by which you can get a redetermination if your plan denies you a service or benefit you think should be covered.
If you disagree with the decision, you can request an independent review.
If that decision is not in your favor, you can proceed up the appeals levels to an administrative law judge, the Medicare Appeals Council and federal court.
In addition, Medicare Advantage companies must give patients a way to report grievances about the plan and the quality of care they receive from providers in the plan.
If you have a Medicare Advantage plan, look at your plan materials or contact the plan administrator for information about filing a grievance or an appeal. For more details, see the Medicare publication “Your Medicare Rights and Protections” or "Medicare Advantage Plans and Medicare Cost Plans: How to File a Complaint (Grievance or Appeal)."
Filing an initial appeal if you have a Medicare Part D prescription drug plan
You have the right to receive a written explanation from your Medicare Part D plan about whether a certain drug is covered, whether you have met the requirements to receive that drug and how much you’ll pay for it.
The benefits booklet provided by your Part D insurer includes step-by-step instructions explaining what you can do if you have problems or complaints related to your drug coverage and costs.
If you believe or your doctor believes you need a medication that isn’t on your plan list, you can ask for a special exception. You also can ask to pay a reduced price for an expensive drug if the less expensive options don’t work for you and your condition.
Anytime you request a plan exception, your doctor, or a health care provider who is legally allowed to write prescriptions, must provide a statement explaining why you should be given an exception.
- Requests for plan exceptions can be made by phone or in writing if you are asking for a prescription drug you haven’t yet received.
- If you are asking to be reimbursed for the price of drugs you have already bought, you must make your request in writing. If your life or health could be at risk by having to wait for a medication approval from your plan, you or your doctor can request an expedited appeal by phone.
- If you disagree with your Part D plan’s decision, you can file a formal appeal. The first level of appeal is to your plan, which is required to notify you of its decision within seven days for a regular appeal and 72 hours for an expedited appeal. If you disagree with this decision, you can ask for an independent review of your case. Your plan will explain the next level of appeal.
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