En español | Filing medical claims is dull work that usually pays off. But, sometimes, it’s just dull. When Medicare, Medicaid or insurance kicks back a claim or request, it can add angst to the already stressful job of caregiver.
“Denied” sounds final and sometimes it is, but it may be just a way station on the road to approval.
Insurance plans, Medicare and Medicaid all have appeals processes and people to walk you through them — but you have to follow their rules. The first is: Don’t procrastinate. Some plans and providers turn unpaid bills over to collection agencies after 60 days. File Medicaid appeals ASAP. The most generous deadline is 90 days from the date the denial was mailed, but state deadlines vary. Check the rules for the patient’s state when the denial arrives. If you miss the deadline, you will have to justify a late appeal. The Medicare cutoff varies depending on if it’s Medicare A, B, C or D.
Steps to Take Before Starting an Appeal
If the service has been completed and the payment denied by Medicare, Medicaid or an insurance plan, do this before starting an appeal:
- Ask the hospital or doctor’s business office for copies of the medical records.
- Compare records with bills. The wrong code or date, a misspelled name, a digit off an account number or incomplete paperwork can be cause for denial.
- If you find a discrepancy, report it to the billing office and ask that it be corrected and the claim resubmitted.
- Ask for an explanation of any questionable charges.
- If the answer is not satisfying, ask to speak with a manager.
If the problem is not in the paperwork, or if your loved one has been denied a medical service or treatment you believe is essential to his or her health, it’s time to appeal. Here's how.
Medicare recipients have the right to appeal denial of the following:
- health care services, supplies, equipment or a prescription medication
- supplies, health care services or prescriptions already received
- skilled nursing, home health care or treatment at a comprehensive rehabilitation facility
If you, the patient or health care provider believe a delay in treatment, service, equipment or prescription drugs might worsen the patient’s condition or situation, ask that the appeal be declared urgent. If the plan agrees, it will be answered within 72 hours (24 hours for drug appeals).
The appeals process differs based on the type of Medicare plan but the Medicare Redetermination Form (PDF) is used by all.
- Fill it out.
- Be certain the Medicare number is correct.
- Do not leave any box blank or question unanswered.
- Sign it. This can be done by the Medicare recipient or the appointed representative.
- Write the patient’s Medicare number on every document you submit.
- If you need help filling out the appeal, contact Medicare.
- Sample Medicare summary notices can be found at:
- A clear, written explanation of why you disagree with the decision. Cite specific reasons the care recipient needs the denied service or item.
- Materials and/or photos that support your case, such as a letter from the doctor, therapist or other health care provider.
Expect a Medicare Redetermination Notice with the verdict either by mail or as part of your quarterly MSN within 60 days after it was received.
- If your redetermination request is granted, you will be informed and need do nothing else.
- If denied, an Explanation of Medicare Benefits or an MSN will be sent, along with the reason for the decision and directions for filing the next appeal.
Note: There are five levels of appeal, each decided by a higher authority than the prior appeal.
If a Medicare prescription drug plan recipient is prescribed a drug not on the Plan D list, and the patient or patient’s doctor believes it is necessary for maintaining current health, you can appeal.
Ask the plan sponsor for an exception. The health care provider who wrote the prescription must submit a declaration saying why the drug is necessary. If a delay might put the patient at risk, the doctor can request an expedited appeal by phone.
If an exception is not granted by the Part D plan sponsor, you may file a formal appeal. The plan is obligated to answer within seven days of receipt.
If you or the doctor believes the delay for a standard appeals process will harm the patient, request an expedited appeal. If granted, plan sponsors must make a decision within 24 hours of receipt.
If you decide to self-pay, go to the drug manufacturer’s website and request a coupon that lowers the out-of-pocket cost of the prescribed drug. The amount of the discount varies.
Medicaid recipients have the right to appeal any denied payment or service.
Step 1. Check approved benefits.
Step 2. Contact your loved one’s Medicaid case manager and request assistance with the appeals process.
Step 3. Call the Medicaid appeals representative for your loved one’s area, explain the situation and request help.
Step 4. If the issue can’t be resolved by phone, fill out an appeals form. (Medicaid’s decision can take up to three months after the appeal is received). The appeal should include:
- the reason you believe the denial is wrong
- your loved one’s Medicaid information
- a letter from his or her doctor stating that the service or procedure is necessary
- scientific evidence or studies that will strengthen your appeal. A good resource: PubMed.gov
More information can be found on the MACPAC website.
Unlike Medicare and Medicaid, private health insurers do not have a single way of doing things. If your loved one’s claim is denied, follow these steps.
Step 1. Call member services. Have the insurance card, patient’s birthdate, Social Security number and letter of denial in hand. Be prepared to get names and take notes.
- Ask why the claim for the procedure, treatment or hospitalization was rejected.
- If there’s a discrepancy between the insurance company and the provider’s billing office, request a three-way call with the two companies and you. If the mistake is clerical — a missing preapproval number, wrong code — the fix may be simple and quick.
Step 2. If the problem is that the insurance company doesn’t cover the service, ask them to provide the guidelines for what they consider medically necessary.
Step 3. If you and the doctor believe the service to be medically necessary:
- Have the doctor provide a letter explaining why the service is essential.
- Research the procedure or service. Reputable studies and scientific evidence that shows the procedure or service to be effective can help make your case. A good resource is PubMed.gov.
Step 4. If the plan is not persuaded by a doctor’s letter and the research you provide, ask the customer rep how to start a formal appeal. Follow instructions exactly.
Step 5. If, in the end, the denial is unchanged but you remain convinced that the verdict is wrong, contact your state insurance commissioner.