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Health Care Reform:

Health Insurance & Affordable Care Act

How to File a Medicare Appeal

Filing a Medicare Appeal continued...

So, you start by working through your 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.

Medicare Prescription Drug Plan. The appeal processes may differ somewhat, because Medicare Prescription Drug Plans are run by private insurance companies with their own rules.

But in general, if your drug plan won't pay for a drug that you need, here are the steps you should take:

  • First, talk to your doctor about the situation to make certain that you can't take a different drug that is covered by your plan.
  • If that's not possible, ask your doctor to write an explanation about why you need this particular drug (be as specific as possible). Then, either you or your doctor can submit the request to the Medicare drug plan.
  • If the drug plan denies your request, you or your designated representative can file a formal appeal by phone or mail. Find out how the appeal process works in your drug plan. Usually, you have to submit an appeal within 60 days of the original coverage determination. The plan must get back to you with a decision within a week, or 72 hours if you've requested an expedited decision. If you need help filing an appeal, get in touch with your state's State Health Insurance Assistance Program (SHIP.)
  • If the drug company denies your appeal, you can appeal again. But this time, your appeal goes to an independent organization that works for Medicare. Your insurer will give you instructions on how to file further Medicare appeals, should you need them.
  • If your Medicare Prescription drug plan doesn't respond to your request, you can file a grievance by calling 1-800-MEDICARE.

For more help understanding Medicare, see WebMD's list of Medicare Resources.

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