Medicare Appeals: Where Do I Begin?

What is an appeal?

As a Medicare beneficiary, you have a right to disagree with a decision made by Medicare. An appeal is an action you take to request a decision made by Medicare be changed. There are three common circumstances people find themselves filing an appeal for:

  1. Making a request to Medicare that a healthcare service, item, or medication needs to be covered.
  2. Making a request for a service or item you have already received needs to be covered by Medicare.
  3. Making a request to change the amount you paid or must pay for a service, item, or medication.

Medicare changes often, so sometimes something that was once covered is no longer covered anymore. If this happens, and you find yourself being billed for something you thought was covered, then you could appeal this if it is a service or item that you find you still need, or if you are being charged for a late enrollment penalty or premium surcharge that you believe is not valid.

How do I file an appeal?

Filing an appeal sounds complicated; however, no attorney is necessary – you can file an appeal yourself at no cost, but if you have an advisor at MWG Direct, then you have someone handling the appeals process for you! Bonus!

If you are filing an appeal for Original Medicare (a service or item under your Part A or Part B), then you have two options for filing an appeal. Your first option is to fill out a Redetermination Request Form. This will need to be filled out correctly and sent to the company who handles Medicare’s claims. Their address can be found on your MSN (Medicare Summary Notice).

Another option is to submit a written request that includes your name, address, and Medicare card number. You will want to include your Medicare Summary Notice (MSN) and circle the items or services that you would like the request a redetermination for. If no Medicare Summary Notice, you can simply submit a list of the item(s) or service (s) that you disagree with. Just be sure to include the dates of service, too. It is important to also include why you disagree with these items and services and include any information that you feel like might help your case. This may require reaching out to your doctor. An answer as to whether your request was accepted or denied should be sent to you within 60 days after your request has been submitted. If denied, information will be provided to you if you would like to move on to the next level (more on this later).

If you are filing an appeal for a Prescription Drug Plan (Part D), this will need to be done through your Prescription Drug Plan. Different circumstances require different actions. If you are requesting to be reimbursed for medications you have already purchased, this must be done in writing to your plan. You can also complete a Model Coverage Redetermination Request form.

If this appeal is for coverage you have not received from your Prescription Drug Plan, they allow you to file an exception request. To do this, you will either fill out the Model Coverage Redetermination Request form, call your plan, or write them a letter.

Depending on the circumstance, you can file an expedited appeal with the Prescription Drug Plan. These have specific criteria, so be sure that you fall in one of the categories before filing an expedited appeal. If this is the case, you can receive an answer on your appeal within 72 hours.

Lastly, if you are filing an appeal for a Medicare Advantage Plan (Part C) this will be similar to a Prescription Drug Plan where your appeal is not with Medicare, itself, but with your plan. Your Medicare Advantage plan will give you directions on the initial denial notice however, you, your representative, or doctor must respond within 60 days of the date for coverage determination. If you miss the 60-day window, then you will be required to provide a reason for missing to move forward.

These appeals do require written requests, so be sure to include your name, address, and Medicare number. You know the drill! List out the services you are requesting a redetermination on and include any information that you feel like will help your case. The time frame for a standard Medicare Appeal is 14 days.

What happens if my appeal is denied?

If your appeal is denied, no need to fret! There are five different levels an appeal can go to:

The First Level: Redetermination by a Medicare Administrative Contractor (MAC)

The Second Level: Reconsideration by a Qualified Independent Contractor (QIC)

The Third Level: Decision by the Office of Medicare Hearings and Appeals (OMHA).

The Fourth Level: Review by the Medicare Appeals Council

The Fifth Level: Judicial Review in Federal District Court

What is the next step after filing an appeal?

According to statistics, Medicare beneficiaries have a strong chance of winning their appeals. The Medicare Rights Center revealed that 80% of Part A appeals and 92% of Part B appeals get approved. It is worth a shot, right?

One of the many services MWG Direct provides is helping clients with Medicare appeals. We will lock arms with you and walk you through the entire process!