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 worth a try.
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, called an “initial determination,” 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 or a “redetermination,” here's what you do:
- Look over the notice and circle the items in question and note the reason for the denia.
- Write down the specific service or benefit you are appealing and the reason you believe the benefit or service should be approved, either on the notice or on a separate piece of paper. Use the “Redetermination Request Form” available at cms.gov, or call 800-MEDICARE (800-633-4227) to have a form sent to you..
- Sign it and write down your telephone number and Medicare number. Make a copy.
- Send a copy to the Medicare contractor's address listed on the Medicare Summary Notice.
- Include any other documentation that supports your appeal.
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 800-MEDICARE (800-633-4227) to get the phone number of your state's Quality Improvement Organization.
If your appeal is denied, you may file another appeal with an independent contractor, called a Qualified Independent Contractor, that was not involved in the original decision. You can download the Reconsideration Request Form for this second level appeal at cms.gov. You must file this appeal within 180 days of getting the denial of your first appeal.
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.
So, you start by working through your insurer, which should have provided you instructions on how to file an appeal. You have 60 days from getting your plan’s denial to fill an appeal, also called a reconsideration. If the insurer denies your appeal, you may request a review by an independent group affiliated with Medicare. Your plan is required to provide you information on how to file an independent review of the plan’s denial.
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. Medicare Prescription Drug Plans are run by private insurance companies with their own procedures for filing appeals although they must follow the rules outlined by Medicare.
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 or fast decision.
- If the drug company denies your appeal, you can appeal again. But this time, your appeal goes to an independent organization that in coontracted by 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 800-MEDICARE (800-633-4227).
If you need help filing an appeal, get in touch with your state's State Health Insurance Assistance Program (SHIP). Your local SHIP can help you whether your appeal is for Original Medicare, Medicare Advantage, or your Medicare Prescription Drug Plan.
If you have exhausted your appeals described above, you can request a hearing before an Administrative Law Judge (ALJ). An ALJ is a special kind of judge that hears disputes regarding benefits you are entitled to, such as Medicare or Social Security. To request a hearing by an ALJ you must fill out a form and send it to the Office of Medicare Hearings and Appeals. You have further judicial rights if your appeal is denied by an ALJ. Check the CMS website for more information on these legal processes.
IMPORTANT: For all appeals, ask your doctor to write a letter of support explaining why you need the service that was denied. Submit this letter with your appeal and any other supporting documents.
For more help understanding Medicare, see WebMD's list of Medicare Resources.