Ever wonder how to submit Medicare appeals to the insurers? A healthcare provider can file an appeal to reconsider any claim partially or completely denied by the insurers. but the situation is quite complicated in case of Medicare denials. Anyone with Medicare knows that there are strict guidelines for reimbursements. However, this does not mean that you have to accept the outcome if a claim is denied. Just like with other insurance companies, patients have the right to appeal a claim denied by Medicare.
Reasons to File Medicare appeals
There are many different reasons that you may want to file a Medicare appeal. Below is a list of the most common things patients are denied coverage for that wish to appeal:
- Medical supplies, prescriptions, and health care services you already receive or use
- New medical supplies, prescriptions, and health care services your provider prescribed for you
- A more expensive or other class of drug your provider states is medically necessary for your treatment plan
In order to begin the Medicare appeal process, you will need the Medicare Summary Notice (MSN)that provides more details about your claim and why it was denied. There are different time limits and requirements for filing an appeal depending on which part of Medicare (A, B, C, or D) you are appealing, so be sure to know which guidelines to follow so that you will not waste your time by filing an appeal incorrectly.
Filing an Appeal for Medicare Part A or B
Once you receive your MSN, you have 120 days to file an appeal. You can write on the MSN or a separate page what you are appealing and why. Be sure to include any additional information to support your appeal including information or a letter from your health care provider.
Read and follow all of the instructions on your MSN to ensure your appeal is filed correctly. Also, make copies of everything you are submitting for your own records. You can then either send the MSN and additional information to the address at the bottom of the last page of your MSN or use a Medicare Redetermination Form (20027).
Steps for the Appealing Process of Part A or B claims
- The first level of appeal is a redetermination (described above).
- If the redetermination does not yield the wanted outcome, then you may elevate it to a level 2 appeal, known as a reconsideration. At this point a Qualified Independent Contractor (QIC) will review your original claim.
- If you are denied a second time, the third level of appeal is an Administrative Law Judge (ALJ). You may want to hire an attorney at this point, but it is not required as it is an informal proceeding. However, evidence and briefs will be filed and presented, so some patients are more comfortable having an attorney present.
- The fourth level of appeal will be the Medicare Appeals Council. This review may require you to have legal assistance for your case. It will be conducted separately from your previous reviews and the minimum claim cost is $160. You must appeal within 60 days of receiving your ALJ hearing results.
- If all else fails, your only chance to get compensation is to file with the Federal District Court. This is a formal court appearance and requires legal representation. You must file within 60 days of receiving your Medicare Appeals Council results and the minimum claim amount is $1560.
Filing an Appeal with Medicare Part C (Medicare Advantage)
Medicare Part C is given through private insurance companies and are required by Medicare to have an appeals process. This includes a redetermination if your private insurance plan denies a benefit or service you think should be covered.
From there you can request an independent review and if that review is denied, you will then proceed up the chain of appeal levels listed above. Medicare Part C companies alsogive patients a way to report complaints about their plan and the quality of care they receive by providers in said plan.
Appeals for Patients with Medicare Part D Prescription Plans
If you want to know what drugs are covered under Part D plans you can receive a written explanation for the drugs, requirements to receive those drugs, and the cost. If you have any problems with your drug coverages and costs, your insurer will provide you with a benefit booklet that explains what you can do to possibly receive a plan exception.
If you request a plan exception, your provider must provide a statement or letter as to why the exception is necessary. If your health could be at risk by waiting for an exception approval, your provider can request an expedited appeal over the phone. You can also file a formal appeal and have an independent contractor to review your case. After that, you will have to check with your insurer on how they handle it on a higher level.
Overall, if you have any further questions about appeals and denials, contact your insurance company. They will be able to explain all of your benefits and answer any questions not explained above.