Medicare appeal - what you need to know
Medicare approves 95% of the claims that are sent to them. However, due to various reasons, Medicare may deny your claim. If Medicare denies one of your claims, you may be able to appeal the decision.
The process of Medicare appeals can vary depending on the coverage type denied. For example, Original Medicare appeals are different than Medicare Advantage appeals or Part D appeals. However, your Medicare plan is required to inform you about how to file an appeal in writing, so you won’t have to guess how the process works.
Regardless of the type of appeal or which coverage type you have, before filing your appeal, make sure you have all the necessary documents to plead your case. This may include doctor’s notes, supplier information, and medical bills.
Appealing Original Medicare decisions
Original Medicare is your Part A and Part B coverage. If you have a Medicare supplement plan or just Part A and Part B alone, you will submit appeals in the following way for Part A and Part B services.
Each quarter, Medicare will send you a Medicare Summary Notice. This notice isn’t a bill, but instead a list of services that were submitted to Medicare on your behalf within those three months. The notice also includes what Medicare paid as well as the amount you are responsible for.
If you see a service on your Medicare Summary Notice that Medicare didn’t cover that you believe should have been covered, you can file an appeal. An appeal for Original Medicare must be submitted within 120 days from the date marked on your Medicare Summary Notice. The first of potentially five levels of the appeal process is the Medicare Redetermination Request Form (CMS Form 20027). Most people only go through one to two levels of the appeal process. People rarely move onto the higher, court-level stages.
Along with this form, send any relevant documents that might help your case, as well as a written letter explaining why you think the service(s) should be covered. The address you send this information to can be found on your Medicare Summary Notice in the appeals section. You should receive a Medicare Redetermination Notice within 60 days of the date Medicare receives your appeal.
Appealing Medicare Advantage plan decisions
Medicare Advantage plans take over Original Medicare’s responsibility in coverage decisions. If you have a Medicare Advantage plan and a service is denied, that decision was solely made by your plan, not Original Medicare. Therefore, your appeal must be filed through your plan, not Medicare.
Your Medicare Advantage plan should send you some form of denial. Once you receive that notice, you will have 60 days to submit your appeal request to your plan. While each plan may have its own process for appeals, generally, you can submit a written request that includes your personal information, such as your Medicare ID number, the services or items you wish to appeal, and relative documentation to help your case. Depending on the urgency of your request, your plan may have anywhere from 72 hours to 60 days to respond.
Appealing Medicare Part D decisions
Like appealing Medicare Advantage plan decisions, Part D appeals will be handled through your Part D plan, not Medicare. A common Part D appeal is a formulary exception. When you file a formulary exception, you are requesting your Part D plan to cover a specific drug that isn’t on the formulary.
Technically, you can file this request before or after you pay for your prescription. However, filing the appeal beforehand can save you time and money if your request is approved. Whether you’re filing an exception or appealing a coverage determination, you will need to submit a Model Coverage Determination Request form to your plan as well as a letter pleading your case.
However, if you are filing an exception, you will also need to include written documentation from your doctor explaining why this non-covered drug is medically needed and why a covered drug isn’t a viable option. Depending on if you’ve purchased the drug yet or not, your plan may have 24 hours to 14 days to provide you with a decision.
As you can tell, appeals can be tricky, and it very much depends on the type of coverage you have. But the important thing to remember is that the people who make the decisions on your appeals are real, live humans with feelings. Sometimes, being kind and patient gets you better results than being angry or rude.
Danielle K. Roberts is a Medicare insurance expert and co-founder at Boomer Benefits, where her team of experts help baby boomers with their Medicare decisions nationwide.