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Health Care Reform:

Health Insurance & Affordable Care Act

How to File a Medicare Appeal

Ideally, Medicare will pay its share of your health costs without you having to do anything. In reality, it doesn't always work that way.

You may sometimes find that Medicare hasn't paid enough -- or at all -- for a drug, a doctor's visit, or a treatment that you needed. Perhaps Medicare stopped paying for a service or a drug it once covered. If that happens, and you feel that Medicare should pay, you can file a Medicare appeal. Filing a Medicare appeal might seem intimidating, but it's usually worth the effort; more than 70% of Medicare appeals are successful. So if you put in the time, the odds are good that you'll get what you need.

Filing a Medicare Appeal

The process of filing a Medicare appeal depends on what type of plan you have.  But the appeal process generally has five levels. So if your originalappeal is denied, you may proceed to the next level and so forth.

Original Medicare Plan (Medicare Part A and Medicare Part B). Whenever Medicare approves (or denies) payment, you'll get a record of it on the "Medicare Summary Notice" you receive every three months in the mail. To file a Medicare appeal, here's what you do:

  1. Look over the notice and circle the items in question.
  2. Write down the reason you're appealing, either on the notice or on a separate piece of paper.
  3. Sign it and write down your telephone number and Medicare number. Make a copy.
  4. Send it -- or a copy -- to the Medicare contractor's address listed on the notice.
  5. Include any other documentation that supports your appeal.

Make sure to file your Medicare appeal within 120 days of the date you received the Medicare Summary Notice.

You may also file a fast appeal if you believe Medicare should continue paying for a service. Your health care provider should provide you with a notice with instructions on filing. You need to call the Quality Improvement Organization listed on the notice to request a fast appeal. If you miss the deadline on the notice, call 1-800-MEDICARE (1-800-633-4227) to get the phone number of your state's Quality Improvement Organization.

Medicare Advantage. Filing an appeal is potentially a little trickier with Medicare Advantage plans. You're dealing not only with Medicare, but with the rules set by the private insurance company that runs your program.

So, you start by working through the individual insurer, which should have provided you instructions on how to make a Medicare appeal. If the insurer denies your claim, it is then reviewed by an independent group affiliated with Medicare.

If you think that your Medicare Advantage program's refusal is jeopardizing your health, ask for a "fast decision." The insurer is legally bound to get you a response within 72 hours.

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