Health insurance companies don’t always pay for items the first time coverage is requested, and they don’t cover everything they’re asked to. You, the consumer, may need to file an appeal to get the coverage you believe you’re entitled to as a plan beneficiary. This is true for private health insurance, and it also sometimes happens with Medicare, the federal health insurance program designed for people age 65 and older and those with qualifying disabilities.
“There are few things more frustrating for Medicare beneficiaries on a fixed income than to find that a claim they expected to be paid was denied for coverage. No one likes a surprise medical bill,” says Bob Rees, chief sales officer with eHealth, Inc., a health insurance broker and online resource provider headquartered in Santa Clara, California.
Here, we’ll walk you through the Medicare appeals process, the information you’ll need to gather and times you might want to consider filing an appeal.
How to Submit an Appeal on a Medicare Claim
Anytime your doctor bills Medicare for a service rendered, you’ll get a statement from Medicare noting what was covered. If some or all of the claim is denied, but you thought an item would be covered under your policy, it may be time to submit an appeal to have Medicare reevaluate their decision to deny coverage and ask them to reconsider.
First, though, it’s important to note that Medicare doesn’t cover everything. While many people assume Medicare covers all their health care needs later in life, such as costs associated with assisted living, that’s not the case, notes Tyler End, CEO and co-founder at Retirable, a retirement advisory company based in New York City. This “blind spot” can be a real problem for some people, he adds.
And just because you think a cost should be covered — for acupuncture, for example — doesn’t mean it will be. You’ll need to read the fine print of your plan’s details before submitting an appeal.
If you have evidence that a claim shouldn’t have been denied, there is a set process for filing an appeal. Rees notes this process can vary depending on the type of Medicare plan you have.
Generally, however, there are five levels of appeal. If you disagree with the response you get at any level, you can move to the next higher level. The process for doing so will be outlined in the decision letter you receive after the appeal review process for the current appeal level has been concluded.
[READ The Parts of Medicare Explained: What They Cover and What They Don’t]
Appeals in Original Medicare
If you’ve received a denial letter for a Medicare claim, you may be wondering how to appeal. For original Medicare (Part A and Part B), start by looking at your Medicare Summary Notice, or MSN. This is a statement that original Medicare beneficiaries get in the mail every four months that details their Medicare Part A and Part B covered services.
If you didn’t get any services or medical supplies during the four-month period covered by a particular MSN, you won’t receive one in the mail for that cycle. You can also opt to have the MSN delivered electronically, so you don’t have to wait for a paper copy in the mail.
The MSN outlines:
— All services and supplies that were billed to Medicare during that period
— What Medicare paid
— The maximum amount you owe the provider (the portion that was not covered by Medicare)
If you see that an item or service was denied, call the health care provider’s office to ensure they submitted the correct information to Medicare. They may be able to resubmit their claim with corrected information, and then you may not need to file an appeal.
However, if the doctor’s office did submit the claim properly, but you were denied, you can move to Level 1 of the appeals process.
[Read: Medicare Fall Open Enrollment: What You Need to Know.]
Level 1 Appeals: Redetermination
After your claim is denied, Rees says, follow the instructions in your denial letter or outlined in your plan details. Your appeal will need to include:
— Your name
— Date of birth
— Your Medicare number
— The date service was rendered
— Names of the items you’re appealing
You can also include additional information to help make your appeal stronger.
“For example,” Rees says, “your doctor may help you by providing a letter or medical records to back up your appeal.”
To streamline this process, CMS provides a “Redetermination Request Form” that you can fill out and send to the Medicare contractor at the address listed on your MSN. This form asks for your contact information, Medicare number and claim in question. It also collects information about why you’re disputing the denial and what additional information you have to support your case that the item should have been covered by Medicare. Mail all documentation to the Medicare Claims office address listed on your MSN.
Most of the time, you’ll get a decision back from Medicare within 60 days of their receipt of your appeal. If your appeal is successful, Medicare will list that covered item or service on your next MSN. If your appeal is unsuccessful, you’ll get a written decision letter called a “Medicare Redetermination Notice.”
If you still don’t agree with the decision, you have 180 days after you get that decision letter or your next MSN to ask for a Level 2 appeal.
[READ: Does Medicare Require Prior Authorization?]
Level 2 Appeals: Independent Review Entity Reconsideration
If your Level 1 appeal is denied, you can move to a Level 2 appeal. Level 2 appeals are made to a third-party independent review entity, Rees says.
Also called a Qualified Independent Contractor, or QIC, this independent contractor won’t have participated in the Level 1 decision and will review your request for reconsideration and make a decision.
When filing this type of appeal, you should send a copy of the Medicare Redetermination Notice with your written request for reconsideration to the QIC. That request should explain why you disagree with the redetermination decision from Level 1.
The QIC’s contact information will be provided in your Level 1 decision letter, and you should hear back from them within 60 days after they receive your appeal request.
“Relatively few appeals go beyond Level 2,” Rees notes.
Level 3 Appeal: Decision by the Office of Medicare Hearings and Appeals
If you’re still unsatisfied with the determination made, you can move up to Level 3. Level 3 appeals are decided by the Office of Medicare Hearings and Appeals, or OMHA, Rees says.
To file an appeal with OMHA, your case must meet a minimum dollar amount ($180 in 2024).
This level of appeal involves a hearing before an Administrative Law Judge (ALJ). In some cases, you might be able to forego the hearing if you ask for an on-the-record review of your appeal by an ALJ or attorney adjudicator.
To request a hearing, follow the instructions listed on the Medicare Reconsideration Notice you received from the QIC at the conclusion of your Level 2 appeal.
During the hearing, you can present your appeal to a new, independent person who will review the facts and listen to your testimony before making a decision. This hearing is usually held by phone or video conference, but it may be held in person if the ALJ deems it necessary.
To request a hearing, fill out a “Request for Administrative Law Judge Hearing or Review of Dismissal” form, which details information about you, the disputed claim and why you disagree with the QIC’s decision from Level 2.
Level 4 Appeals: Review by the Medicare Appeals Council
If you disagree with the OMHA’s decision or the OMHA doesn’t issue a timely decision, you have 60 days to move to a Level 4 appeal, which is made by the Medicare Appeal Council.
You’ll receive directions in the ALJ’s hearing decision letter on how to pursue a Level 4 appeal. You can ask for this review by filling out a “Request for Review of an Administrative Law Judge Medicare Decision/Dismissal Form” or submitting a written request to the Appeals Council that includes your information, the disputed claim and a statement describing what you disagree with in the ALJ’s decision and why.
There’s more information about the Appeals Council review process at HHS.gov, and you can call 1-800-MEDICARE (1-800-633-4227) for assistance with that process.
Level 5 Appeal: Judicial Review in Federal District Court
If you still disagree with the ruling from the Appeals Council, you have 60 days to request judicial review in federal district court — a Level 5 appeal. You can also seek this level if the Appeals Council doesn’t issue a timely decision.
Appeals at Level 5 are restricted by dollar amount; in 2024, the minimum dollar amount is $1,840. If you’re unable to meet this amount, you may be able to combine claims.
The Appeals Council’s decision letter will outline how to request a Level 5 appeal.
Appeals in Medicare Health Plans
Original Medicare isn’t the only game in town for older adults looking for health insurance. For more than half of older adults, Medicare Advantage plans are their primary insurance. These plans also have established appeal processes.
For Medicare Advantage plans, which are approved by Medicare but offered by private insurance companies, the process can vary depending on the company offering the Medicare Advantage plan. But generally, the process is very similar to original Medicare in that there are five levels:
— Level 1: Reconsideration from your plan. You can ask your plan to reconsider its ruling.
— Level 2: Review by an independent review entity. If your plan upholds the denial, they’ll automatically forward that decision to an independent review entity to start a level 2 appeal.
— Level 3: Decision by the OMHA. This level is effectively the same as for original Medicare holders.
— Level 4: Review by the Medicare Appeals Council. This level is largely the same as for original Medicare holders.
— Level 5: Judicial review in federal district court. This level is also essentially the same as for original Medicare holders.
Time is of the essence when submitting an appeal, Rees notes.
“In most cases, a Level 1 appeal must be filed within 60 days of your original denial. Your insurer typically has 30 days in which to make a decision on your appeal, but you can ask for an expedited appeal of 72 hours in some cases,” he says.
In addition to Medicare Advantages plans, there are also appeals processes in place for people with PACE (Program of All-Inclusive Care for the Elderly) and Medicare Cost plans.
— PACE plans: The appeals process is different and handled by the PACE organization, which will give you written information about your rights to appeal.
— Medicare Cost plans: You’ll follow the same appeals process as those with original Medicare, outlined above.
CMS offers additional details about these alternative appeals processes online.
When Should I File a Medicare Appeal?
If you’ve been denied coverage for a benefit or service you believe should be covered, you may want to file an appeal. Some common scenarios for when you might file an appeal include:
— When you feel a medical claim is inappropriately denied, whether the claim was for a health care service, a piece of medical equipment or a medication that you think Medicare should cover
— When Medicare denies coverage for all or part of a health care service, item, supply or prescription drug that was previously covered
— When the coverage you do receive does not meet what you feel is the proper level
— When the amount you’re being asked to pay for a health care service, drug or other item that was previously partially covered changes and you’re now being asked to pay more for that item
— When a request for pre-authorization for a service or drug is denied
— When your use of certain medications raises an alarm and your plan’s drug management program labels you as “at-risk.” This can occur when medications such as opioids and benzodiazepines are being prescribed often, triggering the Overutilization Monitoring System. This may lead your plan to limit your access to coverage for those medications as a means of trying to curb abuse.
Who Can Help Me File an Appeal?
You can make a Medicare appeal yourself or seek assistance from your doctor.
“You can also appoint a representative — for example, a family member — to make the appeal on your behalf,” Rees adds.
There are two ways to appoint a representative:
1. Add a representative through your Medicare account by creating or logging into your online Medicare account and selecting “Account Settings.” From there, click on “My Representatives” and select “Manage My Representative.” Then, you’ll select “Add Representative” to add their name and address. You can edit a representative’s access whenever you want.
2. Submit an “Appointment of Representative” form, which you’ll send in with your appeal to the Medicare Administrative Contractor (MAC). MAC is a company that handles original Medicare claims or your Medicare Advantage health plan. That form collects important information including your and your representative’s contact details, your relationship to one another, your Medicare number, a statement explaining why you’re appointing this person and confirmation that you’re authorizing this person to send and receive identifiable health information on your behalf.
You can also seek assistance from your State Health Insurance Assistance Program. These programs are offered in every state and are staffed by highly trained counselors who will work with you one-on-one to provide unbiased help in navigating all aspects of Medicare, from the initial plan selection to filing appeals if the need arises.
Going through a Medicare appeals process can be confusing and frustrating. And in some cases, you may still end up on the hook to pay for what you thought should be covered. But you do have an opportunity to address that each year during the open enrollment period in the fall, when you can review and adjust your plan selections.
Use this open enrollment period strategically, End advises. Review your options and “select a plan based on your current medical conditions, prescriptions and preferred doctors” and any anticipated changes you might foresee coming up.
While you can’t plan for every possibility, if you take the time to carefully consider your options — and work with a trusted advisor to sift through those choices — you may be able to avoid the need for future appeals.
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How and Why to File a Medicare Appeal originally appeared on usnews.com
