The Medicare Appeals Process

Written by:

Corey Whelan

Reviewed by:

Cassandra Parker

Key Takeaways

Medicare can’t arbitrarily deny your claimA claim is a request for payment to your health insurance company. A claim is usually handled by your doctor or provider, though some plans will make you file your claim if you visit an out-of-network doctor. . They must provide a reason for doing so.
If your health will be in jeopardy during the appeals process, you can request to fast-track it.
The appeals process comprises five levels. Your chances for a successful appeal may increase if you don’t give up after a level 1 denial.
You have 120 days to start the appeals process after receiving a denial for services.
Many people successfully win their appeals.

If you have Medicare, you have the right to appeal a decision that denies your coverage for care. You can also appeal Medicare’s decision to add costs, such as penalties, to your premiums.

If you wish to appeal a decision made by Medicare, understanding and following the Medicare appeals process is essential. Read on to learn the dos and don’ts.

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Original Medicare Appeals

Original Medicare consists of two parts – Part A and Part B. Medicare Part A covers services you receive as an inpatient in a facility, such as a hospital or hospice. Part B covers outpatient services you receive in a doctor’s office, as well as preventive care, durable medical equipment, and other healthcare services.

There are several reasons why Medicare might deny your claim. They include:

Medicare doesn’t consider an item medically necessary and never covers it.
The item or service you need has eligibility requirements that Medicare determines you don’t meet.

If you have Original Medicare, you can file an appeal in situations such as:

You’re being discharged from a hospital sooner than you think is medically appropriate.
A service is being terminated that you think you still need, such as physical therapy.
You’ve been denied prior authorization for a service you think you need, such as an MRI.
Your out-of-pocket cost for a service or item is higher than you think it should be.
You’re being charged a late enrollment penalty for Part B that you think is inaccurate.

If you have coverage under Original Medicare, you may have noticed that you get a Medicare Summary Notice every three months. This summary lists items and services that doctors, suppliers, and other providers submitted to Medicare on your behalf. The notice includes the billed amount, portion you owe, and Medicare’s approval, denial, or partial denial of the claim. If Medicare has denied a claim and you disagree with their decision, you or your representative can file an appeal.

You may also receive an advance notice indicating that a service you currently receive will no longer be covered. There are several different types of advance notifications. They include:

Advance Beneficiary Notice of Noncoverage – an item, service, or prescription that was covered will no longer be paid for by Medicare
Skilled Nursing Facility Advance Beneficiary Notice – Medicare will inform you if they will no longer pay for your stay at a skilled nursing facility.

Appeals With Medicare Advantage

Medicare Advantage (Part C) is an alternative way to get Medicare coverage. Part C is Medicare insurance you purchase from a private insurer.

Part C plans cover everything Original Medicare does, plus other items and services such as dental care and prescription drugs. You may receive denial of an item or service from your Part C provider for the same reasons that Original Medicare denies claims. However, you won’t receive denial for a service that is covered by your Part C plan because Original Medicare doesn’t cover it.

Your plan’s decision to approve or deny your claim is referred to as an Organization Determination. You can ask for this documentation in advance of receiving care. Approval or denial typically takes around two weeks to receive. If you need emergency care or feel that your health will be adversely affected by this wait, you can request that your plan’s insurer expedite their decision.

If you have Part C, you have the right to appeal your insurer’s denial of your claim. You can appoint a representative to go through this process on your behalf, or you can ask your doctor to assist you.

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Medicare Part D Prescription Appeals

Medicare Part D is prescription drug coverage that must be purchased from a private insurer. And like other forms of coverage, you can file an appeal if you think a decision was made in error.

If you have Original Medicare, it is in your best interest to buy a Part D plan when you first become eligible. People with Part C plans usually have Part D coverage folded in and don’t need to buy a separate plan. If you delay getting Part D and don’t have prescription drug coverage through your employer or another source, Medicare may charge you an ongoing late enrollment fee. If you believe you have been charged this fee in error, you have the right to appeal.

Every Part D plan has a formulary, or listing of the medications it covers and the estimated costs you can expect to pay. Not every Part D plan covers every type of medication, although the drugs most usually prescribed are typically included.

Your Part D plan may deny coverage of a prescription drug that is not in its formulary. It may also deny coverage of a prescription drug if you haven’t submitted prior authorization for it. In some instances, your plan may require you to try other, less expensive medications first. This is known as step therapy.

If you need a drug that is not included in your plan, and the plan has no reasonable facsimile for it, you may also appeal this decision by Medicare.

Your Part D plan may also deny coverage for a prescription drug that is over an allotted quantity, such as 40 pills when your plan allots 30 pills per month.

Your pharmacist may be the first one to inform you of Medicare’s decision to deny your coverage. If this is the case, call your plan and ask if they will make an exception. This is known as an exception request. If they refuse, you have the right to file for an appeal.

Medicare Appeals in Special Needs Plans (SNP)

Special Needs Plans (SNPs) are a type of Part C plan. They are tailor-made for people who are living with certain medical diagnosis or qualify due to income level.

People who meet specific financial criteria may be eligible for a D-SNP (dual-eligible special needs plan). Membership in D-SNPs is limited to people who are eligible for Medicare and Medicaid together.

SNPs for people with medical conditions have drug formularies that are designed to fit the specific needs of those with conditions such as diabetes, cancer, or HIV. These plans also provide specialists and other services that are especially helpful or supportive for individuals with these diagnoses.

You must prove eligibility to join an SNP. You must also provide periodic proof that you are still eligible for the plan you enrolled in. If Medicare denies eligibility, you can file an appeal. To be successful, you must have documentation indicating your medical diagnosis, or proof that you’re eligible for both Medicare and Medicaid.

If you’re denied a service, prescription drug benefit, or other healthcare item and are enrolled in an SNP, you also have the right to appeal. The appeals process is the same as it would be for any other type of Part C plan.

Medicare Appeal Forms & Contacts

If your healthcare claim is denied, you’ll receive a written notice from Medicare or from your healthcare plan. The notice you receive will provide information about the forms you need to fill out if you appeal Medicare’s decision. You’ll have 120 days to request an appeal after denial. Some of these forms are:

Redetermination Request Form – used to appeal decisions from Original Medicare
Model Coverage Determination Request Form – used to appeal decisions about Part D
Part C plan forms – Medicare Advantage insurers may provide you with a plan-specific form to fill out. These forms, or their accompanying documentation, will include contact information such as your plan’s mailing address and phone number.

Medicare appeals address

This Medicare appeal form, known as the Redetermination Request Form, can be accessed online through the Centers for Medicare and Medicaid Services (CMS).

Or write to:

Attn: Customer Accessibility Resource Staff
Centers for Medicare & Medicaid Services
Offices of Hearings and Inquiries
7500 Security Boulevard, Mail Stop S1-13-25
Baltimore, MD. 21244-1850

Medicare appeals phone number

1.800.MEDICARE (1.800.633.4227) TTY: 1.877.486.2048

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What Are the 5 Levels of Medicare Appeals?

CMS outlines the appeals process for Original Medicare as follows:

Level 1 – Redetermination by the Medicare Administrative Contractor (MAC)

Level 2 – Reconsideration by a qualified independent contractor

Level 3 – Decision by the Office of Medicare Hearings and Appeals

Level 4 – Review by the Medicare Appeals Council

Level 5 – Judicial review by a federal district court

CMS outlines the appeals process for Medicare Part C and Medicare Part D as follows:

Level 1 – Reconsideration from the plan

Level 2 – Reconsidered determination or review from an independent review entity

Level 3 – Decision by the Office of Medicare Hearings and Appeals

Level 4 – Review by the Medicare Appeals Council

Level 5 – Judicial review by a federal district court

Your claim may be approved at any one of these levels. It also may not be approved at all, even after the process has been completed.

While you’re going through the appeals process, it’s important to keep records and documentation about your claim. It’s also important to follow the instructions you receive from Medicare about submitting written requests and to adhere to the deadlines they specify. Make sure to open any mail or email you receive from Medicare promptly, and request that they communicate with you in the language you are most comfortable with.

How Long Do Medicare Appeals Take?

If you don’t apply for a fast-tracked appeal due to healthcare needs, the five-level appeals process can be quite lengthy.

Medicare usually provides a decision about an initial appeals claim within 60 days of its receipt.

You will have 60 days after denials at each level to move your case up to the next level, if you choose.

How Successful Are Medicare Appeals?

It’s not uncommon for a person to successfully challenge a Medicare claim denial. If you feel strongly that your claim was denied in error, it makes sense to appeal. Enlisting the help of your physician, and in some instances an attorney, may help ensure success.

Many people find this process overwhelming. Your chances of success will increase if you stick with it and go through as many levels as necessary.

The more organized you can be, the better. Make sure to keep all of the documentation pertaining to your claim. You can also find some helpful Medicare appeal letter examples online to make sure your documentation is as thorough as possible.

Medicare Learning Guides

Healthcare is personal. So is choosing insurance. If you are new to Medicare, a beneficiary researching options, or a caregiver, we have tailored Medicare Guides for you.

Sources

Organization Determinations. CMS.gov
Medicare prescription drug coverage appeals. Medicare.gov.
Medicare Redetermination Request Form — 1st Level of Appeal. CMS.gov
Medicare Appeals. Centers for Medicare & Medicaid Services

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