Not every medical service or expense is covered under Medicare Part A or Part B, and sometimes the patient and Medicare administrators disagree over whether an expense should be covered.
If Medicare denies your claim under Parts A or B (hospital coverage or doctor’s office coverage, respectively), you have the right to appeal. But you need to understand the process.
Overview
The Medicare appeals process consists of five levels. The first three levels are pretty straight ahead, if you follow directions. The highest two levels may require some attorney or professional advisor assistance, because of their complexity and the standards of proof required to prove your case.
Expedited appeals
Note: If a care facility is trying to discharge you and you believe you should not yet be discharged, there is an expedited appeals process for this purpose.
Your care facility should provide you with a document called “An Important Message From Medicare About Your Rights.” This document will contain information on how to contact and file an appeal with the Beneficiary and Family Centered Care Quality Improvement Organization in your area. If you don’t receive this document, ask for it.
You must ask for an immediate review not later than midnight on the day of your scheduled discharge. As long as you meet this deadline, you will not be held liable for the full cost of your care until the review board makes its decision.
There is a second level of appeal, which you must initiate before noon on the date of your scheduled discharge. Your ‘Message from Medicare’ document will tell you how to request a Level 2 Fast Appeal, if necessary.
Standard appeals — Requests for Redetermination
For other Medicare denials, the process begins with a Level 1 Appeal — Request for Redetermination.
You must file a written request for redetermination within 120 days of receiving your Medicare Summary Notice. This document will contain detailed information on what documents you need to send and where to send them.
Request for Reconsideration
If your Level 1 appeal is denied, the next step, Level 2, is a Request for Reconsideration by a Qualified Independent Contractor.
This starts the process for a different Medicare benefits administration firm to conduct an independent assessment of your claim. You must file your Request for Reconsideration within 180 days of receiving the decision on your Level 1 appeal. Detailed documentation requirements and mailing instructions will be included in the letter informing you of the results of your Level 1 appeal.
Administrative law judge hearing
If your Level 2 appeal is denied, the next step, Level 3, is to file for an administrative law judge hearing with the Office of Medicare Hearings & Appeals.
You will have to provide the OMHA office with the following information:
- Your name, address, and Medicare number. If you’ve appointed a representative, include your representative’s name and address.
- The appeal number is included on the QIC reconsideration notice, if any.
- The dates of service for the items or services you’re appealing. See your MSN or reconsideration notice for this information.
- An explanation of why you disagree with the reconsideration decision being appealed.
- Any additional information or documents that may help your case. If you can’t include this information with your request, include a statement explaining what you plan to submit and when you plan to send it.
Review by Medicare Appeals Council
If your claim is denied by the administrative law judge, you may file a Level 4 appeal with the Medicare Appeals Council, asking them to review your case.
You have 60 days from the time you receive notice of your unsuccessful Level 3 appeal to file a Level 4 appeal. You can also file this appeal if the OMHA does not provide a timely decision in your Level 3 appeal.
The Medicare Appeals Council is the final level of appeal if your unresolved claim is worth less than $1,850. However, for amounts in dispute of $1,850 and greater, and the results of the Medical Appeals Council review are unsatisfactory, you can get a judicial review from a judge in a federal district court.
At the higher levels of appeals, many patients hire professional representation.
For more information about the Medicare appeals process call us, or call Medicare at: 1-800-MEDICARE, or visit their website, www.medicare.gov.
Rick Niles is the Vice President of Client Strategy at UBF Consulting. During his 30-year tenure in the Benefits industry, Rick has become a top efficiency expert in employee benefits programs and the healthcare ecosystem. His primary responsibilities are in creating more effective proprietary employee benefit solutions that help our customers reposition from antiquated programs to more progressive, efficient and today-relevant-strategies.