With the right Medicare plan and supplements, getting health care coverage should be easy. If you’ve ever had a claim denied, however, you know that Medicare doesn’t always work that smoothly. Learn more about how to appeal a Medicare denial and navigate the appeals process successfully.
When to file a Medicare appeal
You can file an appeal when you don’t agree with a coverage or payment decision that Medicare makes in relation to Part A, Part B, Part C, or Part D. You have the right to appeal if you encounter one of the following scenarios:
- Medicare denies coverage for the health care services, medical supplies, or prescriptions you’ve already received.
- Medicare denies you or your health care provider’s request to cover a service, supply, or prescription.
- Medicare denies you or your doctor’s request to lower the price you pay for a certain prescription drug.
- Medicare stops covering a service, supply, or prescription that you still need.
Common reasons for Medicare denials
- Service not covered by your Medicare plan
- Lack of medical necessity
- Missing or incomplete documentation
- Service was not pre-authorized
If you have Original Medicare (Part A and Part B), you’ll get notice of a denial of coverage through your quarterly Medicare Summary Notice (MSN). You can file an initial appeal within 120 days of receiving the MSN, but in most cases, you’ll want to do so as soon as possible. Whether you’re awaiting Medicare’s decision before proceeding with a service or you need to lower your out-of-pocket costs for a supply you’ve already received, it’s in your best interest to start the Medicare appeals process as soon as possible.
What to expect when you file a Medicare appeal
The Medicare appeals process for Part A and Part B has multiple steps. You may receive a satisfactory decision after the first step, but if you don’t, you’ll need to pursue your appeal for as long as necessary until you get the decision you deserve.
Medicare Appeals process
| Appeal Level | Time Limit | Description |
|---|---|---|
| 1st Level: Redetermination | 14 days | This initial appeal level requires you to start the process by contacting the company that handles Medicare claims. You’ll typically get an answer within 14 days. |
| 2nd Level: Reconsideration | 180 days | If you don’t agree with the initial appeals decision, you can request reconsideration by a Qualified Independent Contractor (QIC). |
| 3rd Level: Hearing | 60 days | If you disagree with the QIC decision, you can request an Administrative Law Judge (ALJ) hearing within 60 days. |
| 4th Level: Medicare Appeals Council | 60 days | If you disagree with the ALJ ruling, you can request a review by the Medicare Appeals Council within 60 days. |
| 5th Level: Federal District Court | 60 days | If you disagree with the Appeals Council decision, you can request a judicial review by a federal district court within 60 days. |
If you need to file an appeal for Medicare Part C or Part D, keep in mind that the process may have fewer steps. Always contact your plan to confirm the timeline, the process, and how to submit your appeal.
How to start the Medicare appeals process
The appeals process for Original Medicare is relatively transparent, and your plan is required to tell you how to file an appeal. While the process can take up to 14 days, you may have the right to request a faster decision. For instance, if waiting for an appeal will put your health in serious jeopardy, you can request an answer within 72 hours.
Whether you’re on the standard schedule or you can use the fast-track appeals process, you will either file a Redetermination Request Form or use the following steps to start the first level of a Medicare appeal.
- Talk with your health care provider or supplier about the service, supply, or prescription in question. Find out as much as you can about why you need it and why your plan should cover it. Gather all the evidence you need before filing an appeal.
- Read over your plan’s instructions for submitting an appeal to familiarize yourself with the process.
- On the MSN, circle the line item that you disagree with and state your case. Write or type your argument on a separate piece of paper and attach it to the MSN.
- Sign your name and provide a contact number where your plan can reach you for more information.
- Make copies of everything you submit, and file the copies away in a secure place.
- Mail the MSN and any attachments to the address that appears on the MSN.
Getting the health care coverage you need should be straightforward, but you’re bound to encounter a few bumps in the road. Now that you know how to appeal a Medicare decision successfully, share this article with family and friends so they understand how to file a claim too.
