Turned down for a Medicare Part A/B medical expense? Appeal! Here’s how.
Note: This is the first part of a three-part post on Medicare appeals.
Has Medicare, a Medicare Advantage, or a Medicare Part D plan turned you down for an expense that you think should be covered? As long as you honestly believe that you the expense should be covered, you should appeal. Definitive statistics are hard to come by, but most claim that more than half of all appeals succeed.
We’ll cover Medicare appeals in three posts because the approach differs for appealing a Part A/B from Medicare Advantage and Part D. This post covers Medicare Part A coverage of in-patient hospital stays, skilled nursing home care, home health care, and hospice care, and Part B coverage of doctor’s services, out-patient hospital care, and other services not covered by Medicare Part A. If you were turned down for payment for a medical procedure, or a doctor’s prescription, by a company that provides coverage under a Medicare Advantage plan, or a Medicare Part D plan, the appeals process is different and we’ll cover that in the next posts.
As with many things related to insurance, it’s often best to get help. Consider contacting a State Health Insurance Assistance Program (SHIP) counselor. They’re trained to help in Medicare issues. A friend, family member, or attorney can also be named as a representative using the Medicare Appointment of Representative form.
Under the Part A/B, if you think Medicare should have paid for, or did not pay enough for, an item or service you received the appeal process is relatively straightforward. Your right to appeal is explained on the back of the Medicare Summary Notice (MSN) (PDF). You should get the MSN every 3 months from the company that handles Medicare claims. The MSN should explain why Medicare won’t pay for an item or service and how to file an appeal. If you file an appeal, it’s important to ask your doctor or provider for any information that might help your case. The steps to filing an appeal for Medicare Parts A and B are typically:
- Circle the items that you disagree with
- Explain why you’re appealing
- Sign the MSN and include your phone number
- Send it to the Medicare contractor identified in the “Appeal Information” section of the MSN
- Include documentation, such as a letter from your doctor that you feel supports your appeal
Make sure that you file the appeal within 120 days of receiving the notice. Sometimes the language can get a little tricky. What you’re actually doing is filing for ‘redetermination’. The notice that you first received that said that a medical claim is denied is the ‘determination’. The redetermination request must be filed with the company that handles Medicare claims as indicated on the MSN. There is no minimum dollar amount that must be in question for you to request a redetermination. The company that handles your Medicare claims should send you a written decision within 60 days of getting your request.
There’s a Medicare Redetermination Request Form (PDF) available on the Centers for Medicare and Medicaid Services site that’s helpful in getting the pertinent information on paper.
Okay, so what if they don’t find in your favor? There are actually four formal levels of appeal that go like this:
- Second Level of Appeal – Reconsideration
- Third Level of Appeal – Administrative Law Judge (ALJ) Hearing
- Fourth Level of Appeal – Medicare Appeals Council (MAC) Review
- Fifth Level of Appeal – Federal Court Review
If you haven’t contacted a SHIP counselor, or another professional specializing in Medicare appeals, prior to filing for redetermination and have been turned down, now is the time. Why forego free help in the first place? If you want to understand the details of the Medicare Part A/B appeals process, check out the document on the Medicare site called, How to File a Medicare Part A or Part B Appeal in the Original Medicare Plan (PDF).
The next post is on Medicare Advantage appeals.
Related Links
- State Health Insurance Assistance Program (SHIP) – For counselors that can help on Medicare appeals
- State-by-State Help for Family Caregivers – Use to find local legal help.
- Medicare.gov – 1-800-MEDICARE (1-800-633-4227)
- Medicare Rights Center – For great resources on Medicare.
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