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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 there has been an error, you can file a Medicare appeal. Filing a Medicare appeal might seem intimidating, but it's usually worth the effort; more than 50% of Medicare appeals are successful.

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 original appeal is denied, you will likely have additional opportunities to make your case.

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 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 you are already receiving. 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. 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.

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