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The Medicare Appeal Process Explained

Understanding the Medicare Appeal Process

If you disagree with a Medicare decision regarding payment or coverage, you may file an appeal. This is true whether you have Original Medicare, a Medicare health plan, or a Part D prescription drug plan. The Medicare appeal process includes five levels, allowing you to continue even if your appeal is denied at one level.

What Is a Medicare Appeal?

An appeal is when you file a formal request to have a coverage or payment decision reviewed.

You can file an appeal if either Medicare or your plan (Part C or Part D) denies a request to:

  • Cover a healthcare service, supply, item, or prescription you believe should be covered
  • Pay for a service, supply, item, or prescription that you already received
  • Adjust the amount you must pay for a service, supply, item, or prescription

Please note that an appeal is not the same thing as a grievance, which is essentially a formal complaint about your plan.

Before filing an appeal, we highly recommend first contacting your provider to rule out billing errors.

Original Medicare Appeals, Level 1

If you have Original Medicare and are denied coverage for a service or item, you should receive a Medicare Summary Notice (MSN) regarding the decision. This details the amount paid (if any) as well as what you owe the provider.

Medicare mail

The MSN includes a host of information, such as all services and supplies received from the provider over the past 90 days. Review it carefully to ensure you understand the denial as well as your rights to appeal.

If you decide to appeal, you have 120 days (4 months) from the day you receive the MSN. Your options for filing include:

  • Completing a Redetermination Request Form and sending it to the contractor listed on the MSN
  • Following the appeal instructions on the MSN (includes circling the decision you disagree with and a written explanation)
  • Mailing a written request to the company handling the claim (must include your name, Medicare number, and written explanation)

You should receive a decision from the Medicare Administrative Contractor (MAC) within 60 days. Every time you submit additional information, the MAC gets an additional 14 days to file their decision. You receive this decision via either another MSN or a letter.

Medicare Appeals Level 2

If you disagree with the decision in Level 1, you have 180 days (6 months) to request a reconsideration from a qualified independent contractor (QIC). Follow the instructions included in the Level 1 decision, making sure you include a written description of why you’re appealing.

You should receive a response within 60 days. However, if two months pass without a decision, you may ask the QIC to move your appeal up to Level 3.

Medicare Appeals Level 3

If you reach Level 3, your appeal goes to the Office of Medicare Hearings and Appeals (OMHA) and an Administrative Law Judge (ALJ). Before going to Level 3, though, your case must meet the minimum dollar amount. This varies every year; in 2019, the minimum amount is $160.

Carefully review the Medicare Reconsideration Notice you received in Level 2 and follow the directions for appealing the decision.

At all levels, if you want your provider to request the appeal on your behalf, you must submit the Appointment of Representative form.

Medicare Appeals Level 4

In Level 4, the Medicare Appeals Council reviews the ALJ’s decision from Level 3. You must provide a description of the issue including the reasons you disagree with the decision. If you’ve chosen a representative, you must also identify this person.

If you disagree with the Level 4 decision, you have 60 days to move to Level 5.

Medicare Appeals Level 5

Level 5 puts your case in front of a federal district court. To do this, your case must meet the minimum amount of $1,630 (in 2019). If you have multiple claims, you may combine them to reach this total.

This is the final level of the Medicare appeal process. As your case goes in front of a federal district court, there is no minimum time limit on when a decision must be made.

Medicare appeal

Medicare Health Plan Appeals

You can also appeal a coverage decision if you have a Medicare health plan (commonly referred to as Part C or Medicare Advantage). Some of the terminology may be a little different, but the process is basically the same, including the five appeal levels:

  1. Reconsideration from your plan
  2. Review by an Independent Review Entity
  3. Decision by OMHA
  4. Review by Medicare Appeals Council
  5. Judicial review in a federal district court

Your rights are different if you receive your Medicare benefits via a PACE plan (Programs of All-Inclusive Care for the Elderly). You need to talk to the PACE organization for specifics to your situation.

This is also true if you have a Special Needs Plan (SNP), which must tell you how to appeal a decision. Any review of the plan’s decision is through an independent organization that works for Medicare, not the SNP.

Medicare Part D Appeals

Your Part D plan should send you a document called an Evidence of Coverage (EOC) that explains your rights. If your plan refuses to cover a prescription medication that you believe you need, you may:

  • Ask the prescriber whether there is another prescription you can take
  • Request a coverage determination from your Part D plan
  • Request an exception from your plan

Medicare offers full instructions for when you can appeal a Part D decision as well as steps to follow for a greater chance of success.

Requesting an Extension

If you missed a deadline to appeal, you may request an extension. There is no definitive list of acceptable reasons for an extension; each case is reviewed on its own merits. Common reasons, though, include an illness that prevented you from filing on time and the MSN being sent to the wrong address.

If you have questions about your Medicare coverage, our licensed agents can help. Just call us toll-free at 855-350-8101. To compare plan options in your area, use our online tool.

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