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Legal and Financial Matters

How to Appeal Denied Insurance Claims

Article Highlights

  • Fast appeals can be requested
  • Take notes when dealing with representatives
  • Get help from a nonprofit group

En español | When an insurance claim for your loved one is denied, there are steps you can take to appeal the decision. Medicare, Medicaid and private insurance companies all accept appeals to denied claims. The process can be confusing and, at times, time-consuming, but it can also be well worth it. Here is a breakdown on how appeals work for each.

See also: Legal Protections Your Loved One Should Know About.

Medicare
Regardless of your loved one's Medicare plan, recipients have the right to challenge any denied payment or service that they feel should have been covered or offered. The process differs based on the type of Medicare plan, but each plan's process is straightforward and easy to understand. Here are the basics of each:

  • Original Medicare: If Medicare didn't cover a test, doctor's visit or any other service you feel should have been covered, whether in part or in full, gather any documents from your loved one's doctor that may bolster your case and file an appeal. The directions on how to file can be found on the back of the Explanation of Medicare Benefits or Medicare Summary Notice you or your loved one will get in the mail, along with details on why something may not have been covered.

  • Medicare Managed Care Plans: Under these plans, recipients and their caregivers who feel that a service should have been paid for, whether in part or in full, or feel they should receive a service they were denied, should file an appeal. Also, an appeal should be filed if a Medicare managed care recipient feels a service that should be covered or provided was stopped short.  

    Fast decision options are offered to those who believe their health could be compromised while awaiting a decision and are answered within 72 hours.

    Directions on how to appeal are provided, in writing, by the Medicare managed care plan. Review your membership materials or call your loved one's plan for more information.

    If, after review, your loved one's plan sticks with its original decision, all is not lost. The appeal will then be reviewed by an independent organization working for Medicare.

  • Medicare Prescription Drug Plans: If a Medicare prescription drug plan recipient is denied a Part D prescription drug, or coverage of a Part D prescription drug, by a plan sponsor, and the recipient believes this has been done in error, an appeal should be filed. As with Medicare managed care plans, the directions on how to appeal are provided, in writing, by the plan. Standard appeals must be addressed within seven days after the request is received. Fast appeals can be requested by plan recipients, or their caregivers, who feel that their health will be adversely affected by waiting seven days for an answer. If granted, plan sponsors must answer the appeal within 72 hours of receipt. If the plan sponsor opts not to change its stance on your coverage despite the appeal, there are additional steps that can be taken. Review your loved one's plan sponsor's membership materials or contact the plan sponsor by phone for a full explanation.

For a full explanation of the Medicare appeals process for all plan types, visit Medicare's website. Go here for appeal forms.

Medicaid
As with Medicare, any recipient of Medicaid has the right to appeal any denied payment or service. First, contact your loved one's Medicaid case manager, who will help guide you through the appeals process. It begins with either a call or a letter to the Medicaid appeals representative for your loved one's area. If the issue isn't resolved over the phone, an appeals form will need to be filled out including the reason for your appeal along with all of your loved one's Medicaid information. Include a letter from your loved one's doctor stating the necessity of the service or procedure as well as any scientific evidence you can find backing up your appeal. After receiving your appeal, Medicaid's decision can take up to three months. For more information on this process, visit Medicaid's website.

Next page: Handling private insurance appeals. »

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