First, know that you have the right to appeal if Medicare denies your claim. The process, which has up to five levels of appeals, has specific instructions and time frames for each step.
What steps should I take if I disagree with a claim decision?
With original Medicare, you may be able to solve some Medicare claims issues without going through the appeals process.
When you have a question about a claim, first review your Medicare summary notice (MSN), which lists all services and supplies that providers billed to Medicare on your behalf. Medicare sends this notice to enrollees every three months and breaks out claims for Medicare Part A and Medicare Part B separately.
The first page summarizes all claims and costs for the period, adding this statement: “Did Medicare approve all claims?” It also shows how much of the annual deductible you've paid already. So even if your claim was approved, you may owe money if you haven’t met your deductible.
The third page has details about the claims, including dates, whether a claim was approved, charges not covered, the amount Medicare paid and the maximum amount you may be billed.
Your online Medicare account has updates more frequently than the paper version. You can access information within 24 hours after a claim is processed.
If your claim was denied or you disagree with the amount you may be billed, contact the provider — a phone number is on the notice — and ask for further itemization for the claim. Confirm the provider sent the right information to Medicare, and if some of the details are wrong, ask the provider’s billing office to contact Medicare and correct the errors.
How do I file an appeal for my claim?
If you still disagree with the claim decision as an original Medicare beneficiary, you have 120 days after receiving the MSN to file an appeal.
The last page of your notice lists the date that the Medicare claims office must receive your appeal. This level is called redetermination, meaning a Medicare administrative contractor not involved in the initial claim decision will review your claim.
You must file your appeal in writing. The last page of the MSN lists the steps to take:
- Circle the services or claims you disagree with on the MSN.
- Explain in writing why you disagree with the decision. Include your explanation on the notice, or attach a separate page to the notice if you need more space.
- Fill in your own or your authorized representative’s full name, phone number and your Medicare number.
- Include any other information about your appeal. You can ask your doctor, health care provider or supplier for information that will back up your claim and help your case. Write your Medicare number on all documents that you send and make copies for your records.
- Mail the notice and all supporting documents to the address listed on the last page of your MSN.
Another option is to file a Form 20027, Medicare Redetermination Request Form. If you need help filing your appeal, you can call 800-MEDICARE or contact your State Health Insurance Assistance Program (SHIP).
You’ll generally get a decision, called a Medicare redetermination notice, from the administrative contractor within 60 days after receiving your request. If your claim is approved, it will be listed on your next Medicare summary notice.
What if my claim is rejected again? Can I appeal?
Yes, if Medicare denies your redetermination request, you have the right to pursue up to four more levels of appeals. The notice you receive with the decision at each level includes instructions for pursuing the next level of appeal.
Level 2, reconsideration
- File within 180 days of receiving your Medicare redetermination notice.
- Who reviews the request? A qualified independent contractor (QIC) who didn’t participate in the Level 1 decision.
- How it happens. The contractor will review your written request, including your explanation of why you disagree with the Level 1 decision. Information you submitted at Level 1 will be sent to the contractor to review, and you can also send additional information that may help your case.
- When to expect a ruling. Expect it in writing about 60 days after the QIC gets your appeal request.
Level 3, Office of Medicare Hearings and Appeals
- File within 60 days of receiving the reconsideration decision if your claim is worth at least $180.
- Who reviews the request? An administrative law judge in the Office of Medicare Hearings and Appeals, which is independent from the Centers for Medicare & Medicaid Services (CMS).
- How it happens. You present your testimony to the administrative law judge in a hearing, usually via phone or videoconference. The judge reviews the facts of your appeal before making a new decision. You can have a lawyer represent you.
- When to expect a ruling. Within 90 days or you can appeal to the next level.
Level 4, Medicare Appeals Council
- File within 60 days after receiving the administrative law judge’s decision.
- Who reviews the request? Administrative appeals judges, independent from both CMS and the Office of Medicare Hearings and Appeals but within U.S. Department of Health and Human Services.
- How it happens. These judges review written materials from your previous appeals and your statement explaining why you disagree with the Level 3 decision.
- When to expect a ruling. Within 90 days or you can appeal to the next level if your claim is worth at least $1,760 in 2022.
Level 5, judicial review
- File within 60 days if your claim is worth at least $1,760 in 2022. Follow the directions in the Appeals Council’s decision letter.
- Who reviews the request? A federal judge in the district where you live.
- How it happens. Your disputed claim becomes a civil case filed in U.S. District Court. Also be aware that a provider of services with a previous unfavorable ruling is allowed to request this judicial review.
- When to expect a ruling. The federal Social Security Act, which was expanded to cover Medicare in 1965, does not specify a timeframe for a judge to issue a decision.
Keep in mind
These steps are for appealing claims decisions in original Medicare and don’t apply to claims filed through a private Medicare Advantage plan or a Part D prescription plan — although the process is similar.
A company’s officials review your appeal in Level 1, redetermination. After that, an independent review entity that solicits responses from your insurer as well as potential providers of your services and supplies is involved in Level 2. The remaining levels are the same as for original Medicare.
If your claim involves a prescription drug or service that you need now and can’t wait to receive as you go through the appeals process, you can request an expedited appeal. Review the denial notice or contact your plan for more information about the steps and deadlines for filing an appeal.
Published December 2, 2022
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