Medicare: Appealing Denials

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Transcript: If you are denied from Medicare, you have the option to appeal the decision through a multi-level process. The appeals process works differently for each part of Medicare and depends on whether you are denied healthcare services, supplies, or prescription drugs. You typically will receive your denial on the Medicare Summary Notice (MSN), which is an explanation of benefits over three months. The MSN shows all the services or supplies that providers and suppliers billed to Medicare during the 3-month period, what Medicare paid, and the maximum amount you may owe the provider. The last page of the MSN gives you step- by-step directions on when, where, and how to file an appeal. There are very few services requiring Prior Authorization in Original Medicare, so most appeals for Medicare Parts A and B take place after the service is provided. When appealing, you can request a healthcare service, supply, item, or prescription drug that you think you should be able to get, or payment for a health care service, supply, item, or prescription drug that you have already received, or a change in the amount you have to pay for a healthcare service, supply, item, or prescription drug. You can ask for an expedited (faster) appeal decision for services received from a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation, or hospice. The last page of the MSN gives you step- by-step directions on when, where, and how to file an appeal. To appeal, you need to explain the reason you are appealing the coverage, sign the form, and send it back with supporting documentation, such as health records provided by your doctor, a letter from their office detailing your medical history and why you need this treatment, and any peer-reviewed journal articles supporting the need for this care. Your doctor can help with the appeal too. All documentation submitted should support the reasoning that Medicare should cover the claim. A representative (for example, a friend, family member, social worker, or patient advocate) can complete the appeal on your behalf, but they need to submit an Appointment of Representative form. You cannot appeal a service or item that is not considered a covered benefit under Medicare. There are 5 Levels of Medicare Appeals with each level based on a specific dollar amount of the claim: Redetermination, Reconsideration, Administrative Law Judge Hearing, Medicare Appeals Council Review, and Federal District Court Judicial Review. The first level of appeal is called Redetermination. Claims at this level can be any dollar amount. The appeal must be filed within 120 days (Original Medicare) and 60 days (Medicare Advantage or Part D plan) after receiving the MSN. The second level of appeal is called Reconsideration. You can file a reconsideration if you don’t agree with the decision made during the first-level appeal. Claims at this level can be of any dollar amount, and second-level appeals must be filed within 120 days (Original Medicare) and 60 days (Medicare Advantage or Part D plan) of receiving the decision. Instructions for filing will be provided in the Redetermination Notice. The third level appeal is the Administrative Law Judge (ALJ) Hearing or attorney adjudicator. If you decide to appeal at this level, you may want to contact a lawyer or legal services organization to help you with this or later steps in your appeal, but this is not required. To request an ALJ hearing, you need to send the paperwork within 60 days of receiving the second-level appeal decision. Your claim must meet a certain minimum dollar amount as stated on the Medicare Reconsideration Notice. If you have more than one denial, you can combine the claims to meet the minimum dollar amount. If you disagree with the decision made during the ALJ hearing, you can file an appeal (the fourth level) called a review by the Medicare Appeals Council (The Council). To request this review, you need to submit the request within 60 days of receiving the third-level appeal decision. Your claim must meet a minimum dollar amount as stated on the ALJ Hearing notice. A fifth-level appeal is called a Federal District Court Judicial Review. If you disagree with the Appeals Council’s decision at the fourth level, you have 60 days after receiving the decision to request a hearing at the Federal District Court Judicial Review. To be able to request a federal review, your case must meet a minimum dollar amount. To proceed, you must follow the instructions in the Medicare Appeals Council decision letter on how to file a complaint. [The screen fades to show a thumbnail of a faded white background of a doctor holding hands with another individual] Deaf. Healthy. DeafHealth. Learn more at www.deafhealthaccess.org. [The screen fades to show a thumbnail of a blue lighthouse] Paf. Patient Advocate Foundation. www.patientadvocate.org.]