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The Medicare Appeal Process

Having a claim for medical services denied by Medicare can be very disheartening; especially when you are convinced that your medical services should have been covered.

It is true, that in most cases Medicare will pay for medically necessary services and for charges that are considered to be reasonably billed by the medical provider. Unfortunately, there are times when it does not work that way and an individual must submit a Medicare appeal letter.

The Five Step Medicare Appeal Process

Step 1 - Health Plan

If you disagree with a Medicare coverage decision, you may request your health plan to redetermine your claim.

Step 2 - Independent Organization

If you disagree with the decision in Step 1, you may request a reconsideration by an independent organization.

Step 3 - Office of Medicare Hearings & Appeals

If you disagree with the Step 2 decision, you may request that OMHA review your claim though an Administrative Law Judge hearing.

Step 4 - Medicare Appeals Council

If you disagree with the Administrative Law Judge's decision, you may request the medicare Appeals Council review your decision.

Step 5 - Federal Court

If you disagree with the Medicare Appeals Council Decision, you may seek to review your claim in Federal District Court.

The Importance of a Medical Appeal Letter

Whether you are enrolled in an Original Medicare, Medicare Advantage, or a Medicare prescription drug plan you have the right to submit an appeal letter if Medicare does not pay for medical services that you have been given, or if you are not given an item or service you think you should get.

The process of filing a Medicare appeal might seem to be difficult, but it's often worth the effort to write the appeal or have one written for you.

How to file a Medicare appeal

If it becomes necessary for you to file an appeal, ask your doctor or provider for any information related to the bill that might help your case. The process to follow for filing a Medicare appeal depends on whether you are enrolled in Original Medicare or Medicare Advantage and also on whether the denied services are for Medicare Part A, B or D.

Appeals for Original Medicare Part B (outpatient & doctor expenses)

Your appeal rights are listed on the back of the Explanation of Medicare Benefits or Medicare Summary Notice that is mailed to you from your Medicare insurance carrier. The Explanation of Benefits statement and the Medicare Summary Notice will provide you with a detailed explanation on why your bill was not paid and what appeal steps you can take.

Appeals for Medicare Advantage/Managed Care Plans Part B (outpatient & doctor expenses)

For individuals who are in enrolled in a Medicare Advantage plan, the plan you are enrolled in must tell you in writing the steps to follow when filing an appeal. A fast track decision must be offered to you if you think your health could be seriously harmed by waiting for a decision about a service. If a fast track appeal is filed the plan must provide you an answer within 72 hours.

After you file an appeal, the plan will review its decision. Then, if your plan does not decide in your favor, the appeal is reviewed by an independent organization that works for Medicare, and not for your insurance plan. See your plan's membership materials or contact your plan for details about your Medicare appeal rights.

More information on the Medicare Advantage/Managed Care appeal processes can be found on the Medicare Managed Care Appeals & Grievances webpage: www.cms.hhs.gov/MMCAG.

Appeals for Medicare Part A (hospital) for both Original and Managed Care Plans

If you are admitted to a Medicare participating hospital, you should be given a copy of the Important Message from Medicare notice. This form explains in detail what your rights are as a hospital patient.

The Message provides an individual with the following information:

Quality Improvement Process Organizations and their role in the appeal process

The Centers for Medicare Services contracts with one organization in each state, as well as the District of Columbia, Puerto Rico, and the U.S. Virgin Islands to serve as the Quality Improvement Organization (QIO) for that respective state/locale. QIOs are private, mostly not-for-profit organizations, which are staffed by professionals, mostly doctors and other health care professionals, who are trained to review medical care and help beneficiaries with complaints

Should questions arise regarding the Medicare Part A appeal process you can call 1-800-MEDICARE and request that a Quality Improvement Organization (QIO) review your case. You may be able to stay in the hospital at no charge, while your case is being reviewed by the Quality Improvement Organization. A hospital cannot force a patient to leave until a decision is made by the Quality Improvement Organization.

Appeal for Medicare Part D (Prescription Drugs)

Individual's enrolled in a Medicare prescription drug plan, have the right to appeal an insurance carrier's decision to deny payment for a Part D prescription that was previously authorized. The Medicare prescription drug plan carrier must provide written documentation on how to request an appeal or file a grievance.

As with Medicare Parts A & B an individual can request a fast track decision on an appeal that they have submitted. Under Medicare Part D the carrier must respond within 72 hours. All other Medicare Part D appeals must be answered within 7 calendar days after receiving your request.

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