How to Appeal Medicare Advantage/HMO coverage denial

Posted by awhite
March 10, 2009

Note: This is the second part of a three-part post on Medicare appeals.

Medicare Advantage (formerly Medicare Part C, and often referred to as a Medicare HMO) appeals are different from those of Medicare Part A/B in that you’re appealing to the independent company that provides your Medicare benefits. You’ll need to contact your provider and ask about the appeals process. Most have information on appeals on their websites, including official forms. Your initial appeal is with your provider. We say initial here because as with most appeals processes, they can have multiple levels.

The first thing you have to do is decide whether you want to take on an appeal on your own. We recommend educating yourself about the process, AND getting 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.

You may see the term ‘organization determination’ in relation to the appeals process. Organization determination is simply the initial decision about whether the provider will cover the medical care or service you request, or pay for a service you have received. Providers routinely make the organization determination when your physician submits a charge for payment. A plan must respond to the request within 14 days of receipt, unless an extension is required. There’s also what’s known as an ‘Expedited Organization Determination”, which is usually made when a longer delay could potentially jeopardize the life, or health, of the member. In these cases, a response in 72 hours is required. If the request is denied by the plan, the member should be notified in writing the reason for the denial and advised of further appeal rights.

So, when you’re provider denies payment for a treatment, you have the option to appeal. You, or your representative, must appeal in writing within 60 calendar days from the date of the notice of the organization determination. Your appeal must include:

If someone other than the member is making the request, documentation identifying the individual’s authority to act on behalf of the member, such as a completed “Appointment of Representative” form must be included.

An appeal will be expedited and a decision made within 72 hours if a physician, orally or in writing, supports that the standard time frame for a grievance or appeal would seriously jeopardize the life or health of the member, or would jeopardize the ability to regain maximum function.

So, what if the plan again denies the request for reconsideration? The appeal should automatically be sent by your plan provider to an Independent Review Entity (IRE) for review. The review will be expedited if the IRE determines that your life or health may be seriously jeopardized by waiting for a standard decision. You may submit additional information to the IRE.  The IRE must receive the information 10 days after receipt of the IRE letter acknowledging receipt of the case file. A copy of the submission must be provided to the plan.

If the IRE didn’t rule in your favor, you still have three additional levels of appeal.

If you haven’t contacted a SHIP counselor, or another professional specializing in Medicare appeals, now is the time. As we’ve said before, why forego free help in the first place? If you want to understand the details of the Medicare Advantage appeals process, check out this section of Medicare’s site.

In the next post, we’ll cover Medicare Part D appeals.

Related Links

Medicare

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