Here are some basic steps for challenging Medicare coverage denials under Part A (including hospitalization, nursing homes and hospice services) and Part B (doctor visits, tests, home health care, durable medical equipment). In most cases, it is not necessary to hire a lawyer. Advocates say to be sure to write your Medicare or member number on all documents, and to keep copies.
For the first appeal, called redetermination:
–Circle the questionable item on your quarterly Medicare statement, called the Medicare Summary Notice, and follow the mailing instructions on the form. You can also complete an appeals form at www.medicare.gov/claims-and-appeals/file-an-appeal/original-medicare/original-medicare-appeals.html.
–Make the request within 120 days of receiving the denial.
–Any dollar amount can be appealed.
If you get denied again, you can make a request for second appeal, called reconsideration:
–Make the request within 180 days of receiving notice that the first appeal was denied.
–In a letter, explain the services or items that you received and why payment for them is in dispute. Include a copy of the initial denial or fill out the reconsideration form available at www.medicare.gov/claims-and-appeals/file-an-appeal/original-medicare/original-medicare-appeals-level-2.html.
To request a hearing before an administrative law judge, which usually is conducted via conference call with patients, doctors and others:
–Make the request within 60 days of receiving the denial of the second appeal.
–To be eligible for a hearing, the amount in dispute must be at least $130 in 2012 and $140 in 2103. In your letter, provide your name, address, Medicare number, document control number from previous denial, dates of services or items in dispute and why you are appealing. Include any other information to support your request, or complete a hearing request form available at www.medicare.gov/claims-and-appeals/file-an-appeal/appeals-level-3.html.
If you get denied again, you can make a request for consideration by the Medicare Appeals Council:
–Make this request within 60 days of receiving the hearing decision.
–In a letter, cite which parts of the decision you dispute and the date of the decision, or complete the hearing review request form available at www.medicare.gov/claims-and-appeals/file-an-appeal/appeals-level-4.html.
Beneficiaries who are still not satisfied can file an appeal in federal court. The amount in dispute must be at least $1,350.
Patients may file an expedited appeal if they are being discharged from a nursing home, hospice, outpatient rehabilitation facility or told that home health care is being terminated (not reduced). Providers must give patients notice two days before discharge or termination. Information on this appeal is available at http://www.medicare.gov/claims-and-appeals/right-to-fast-appeal/non-hospital/fast-appeals-non-hospital-setting.html. Coverage for services will continue until a decision is made.
Patients who feel they are being discharged from the hospital too soon may get information about an expedited review of the decision at http://www.medicare.gov/claims-and-appeals/right-to-fast-appeal/hospital/fast-appeals-in-hospitals.html. Coverage for services will continue until a decision is made. (There is a separate procedure for Medicare Advantage plans.)
Beneficiaries in Medicare Advantage plans follow similar appeals procedures, except the initial appeal must be made within 60 days of the denial. Information can be found at http://www.medicare.gov/claims-and-appeals/file-an-appeal/medicare-health-plan/medicare-health-plan-appeals.html. If a service or treatment has been denied, an expedited appeal can be requested from the plan if waiting for a regular appeal decision could jeopardize the member’s health. Expedited appeals are not permitted solely for payment denials. For more details about expedited Medicare Advantage appeals, see section 50 of the Medicare Managed Care Manual at https://www.kff.org/wp-content/uploads/sites/2/2012/12/mc86c13.pdf .
Prescription Drug Plans
Decisions made by Medicare prescription drug plans can also be appealed. Beneficiaries should request a written explanation from the plan why a prescription is not covered and ask for an exception if you or the prescriber believe you need the drug. Beneficiaries pay for the drug until the denial is overturned (during that time, drug discount cards or manufacturer or pharmacy discounts may reduce the cost). An expedited appeal is also an option for those who can’t wait. More information is available at http://www.medicare.gov/claims-and-appeals/file-an-appeal/prescription-plan/prescription-drug-coverage-appeals.html.
For More Help
For free, individual assistance and more information, contact your State Health Insurance Assistance Program at https://shipnpr.shiptalk.org/shipprofile.aspx or find it by calling your county office on aging.
Additional details are at www.medicare.gov/claims-and-appeals and 800-MEDICARE (800-633-4227).
The Center for Medicare Advocacy’s free self-help appeals packets include tips for avoiding appeals; they are available at www.medicareadvocacy.org/take-action/self-help-packets-for-medicare-appeals.
The Medicare Rights Center, a consumer advocacy group, provides appeals advice and other Medicare information at 800-333-4114.
Sources: Center for Medicare Advocacy, U.S. Centers for Medicare & Medicaid Services.