Parenting Upward

Understanding Medicare: Filing a Medicare Appeal

filing a medicare appeal

The medicare appeals process varied by part

Should you consider filing a Medicare Appeal?

There are a few situations in which you may want to consider helping your parent or loved one file Medicare appeal.

  • Denials for services already received, including prescriptions or supplies.
  • Denial for a request for services not yet received, including prescriptions or supplies.
  • Denial to change the price paid for a prescription drug.

As there are 4 parts to Medicare, Medicare A, Medicare B, Medicare C, and Medicare D, the appeal process varies depending which part of Medicare you are appealing. They each have their own requirements and time limits.

For Medicare Part A & B

  • You have 120 days after you received the Medicare Summary Notice with the disputed item or denied claim.
  • Circle the item on the Summary.
  • Attach a clear summary explaining why you believe Medicare’s decision is wrong.
  • Attach any additional documentation. It would be a good idea to talk to your loved ones doctor, health care provider or health equipment supplier for any support in providing documentation or information that could help your appeal.
  • Make sure you read the specific instructions about filing your appeal located on the Medicare summary notice.
  • Sign your name and include your contact information
  • Make copies of everything and keep a file for this sort of information
  • Send the appeal with delivery tracking/confirmation so you can be sure it was received and when .
  • You can use the Medicare Redetermination Form to help you with the first level of appeal.

The Medicare Appeals process has 5 steps.

The first step is called a “Redetermination

The second step is “Reconsideration.” An independent review is made on your appeal.

The third level requires an administrative law judge. It would be a good idea to seek the help of an attorney or legal counsel if you reach this level of appeal. Although the appeal may not be in a courtroom setting, the process is much like a legal proceeding including evidence, witnesses and briefs.

The next step is to appeal to the Medicare Appeals Courts, which is part of the US Department of Health and Human Services.

Finally, there is a 60 day window to file an appeal to the Federal level if your appeal is unsuccessful with the Medicare Appeal Court.

For more information on the appeals process see Medicare.gov’s page on filing an appeal.

 

Appealing  Medicare  Advantage (Medicare C)

 

While Medicare A & B are administered by the government, Medicare Advantage Plans are administered by private insurance companies. Medicare requires these companies to have an appeal process like the Medicare appeals process for part A & B.

If you disagree with a decision Medicare Advantage administrator made you can request an independent review, the proceed through the appeal process to an Administrative law judgethe Medicare Appeals Court and finally to Federal court.

Medicare advantage companies must have a complaints and grievances policy and process for subscribers to report any concerns about the plans, care and services they receive.

Medicare Part D Appeals

Medicare part D is the prescription drug benefit. Under Medicare part D you have a right to be provided with a written summary from Medicare Part D that includes:

  • If a drug is covered
  • If you have met the requirements to receive that drug
  • How much you will pay for it.

Your Medicare Part D insurer should have provided you with a benefits booklet which should include instructions on what to do if you have complaints about your drug coverage or costs.

  • If you are seeking and exception, you will need your doctor or health care provider who has requested the prescription to provide a statement t explaining why the drug should be necessary exception
  • If you are asking for reimbursement for a prescription you have already bought, you must submit your request in writing. However, if your life or health could be at risk by a denial or a wait for approval, you or your doctor can call to request an expedited appeal.

If you have exhausted the options above and are still denied, you can file a formal appeal.

The first level of appeal is to your plan.

For regular appeals, your plan has 7 days to respond and notify you of their decision.

For expedited appeals, your plan has 72 hours to respond and notify you of their decision.

 

Just like with Medicare, A,B & C, the next level of appeal is the ask for an independent review. If this is not successful your plan will explain the next steps in their appeal process as it varies.

 

Help filing a Medicare Appeal

Your loved one has rights related to the appeals process, you can find more information at Medicare.gov

If your loved one needs help filing an appeal you can try reaching out to the State Health insurance Assistance e Program. (SHIP)

If your loved one wants to appoint a representative, be it you or someone else to act on their behalf, follow the process outlined here on Medicare.gov

If your Medicare Part D plan provider is not responding to you in your appeal, you can report them to Medicare at 1-800-Medicare.