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Medicare Appeals Process | How It Works & Tips For Winning

Millions of Americans rely on Medicare for health care coverage and payment for essential medical services. However, payment of Medicare claims is often denied for a number of different reasons. This can put someone in a bind financially and leave them wondering how they will pay for their medical bills or prescription drugs. So, do you have any options if you receive a Medicare denial of your claim? Yes! You can appeal Medicare’s decision through several different levels – even all the way to Federal court! We will explain everything that you should know about the Medicare appeals process as well as give you some great tips for winning your appeal.

 

Overview Of Medicare Appeals Process

If you disagree with a decision by Medicare on whether to provide coverage or payment for a certain medical service, then you have certain appeal rights. You can make an appeal request for Medicare to reconsider their decision. There are five levels to the appeals process although they may not all be necessary for your specific appeal. The five levels will be discussed in more detail in the next section, but here are more specifics about the types of decisions that may be appealed.

If Medicare denies your request to cover a certain medical service, supply, item, or prescription drug that you believe they should cover, then you can appeal that decision. Likewise, if they deny payment for a service or medical item for which you have already received, that decision can be appealed. You might also request that they change the amount you must pay for a service or drug, and you can appeal that decision if your request is denied.

Finally, you have the right to appeal if Medicare stops providing payment for a service, supply, item, or drug that you believe you still need. The type of plan that you are enrolled in determines which level of the appeals process you need to start with. This will also determine who hears the appeal and makes the decision. If your appeal fails, then you may choose to appeal to the next level and continue up from there until you reach Federal District court.

 

Five Levels Of Medicare Appeals

Similar to the court system, there are different levels of appeals in Medicare. If you are unsuccessful at one level, then you can appeal to the next level. If you go all the way to the top, you could end up in Federal court. In practice though, very few appeals make it that far. Here are the different levels and what you need to know about each.

 

— Redetermination

Level 1 of the appeals process is the simple redetermination request. This basically means that you are asking the administrator of your health plan to make a redetermination of whether the service or item in dispute should have been covered when you disagree with the initial determination. In some cases, you might be asking them to make a new determination of how much Medicare should pay. Your health care plan provider is where this request goes. For instance, if you simply have Medicare Part A or Medicare Part B, then your request will typically go to a Medicare administrative contractor (MAC). If you have a Medicare Advantage Plan, then the provider of that plan will handle the redetermination request. This is typically the easiest and most common of the appeals and you can use a simple redetermination request form found on CMS.gov. This is sometimes called a Medicare Appeals Form. Remember that almost all levels of appeal require a written request.

 

— Reconsideration

The next step is the reconsideration request. What happens here is that an independent entity will review the records in your case independently of the original determination. This review is performed by a qualified independent contractor (QIC) for Medicare Parts A & B. For Parts C or D, the review is done by an independent review entity. You will want to clearly explain why you disagree with the redetermination decision, and you will need to include all the evidence that you need. This typically includes all the records from your health care provider as well as any communication with your health insurance company. Introducing new evidence or additional information at a higher level of appeal is usually not allowed unless you can show good cause why the evidence should be allowed. A panel of physicians might review evidence at this stage to help the independent contractors make a decision on medical necessity of a service or procedure.

 

— Office Of Medicare Hearings And Appeals

The third level of appeals goes to the same entity regardless of your plan type. Whether you have original Medicare, a Medicare Advantage Plan (Part C), or a Medicare Part D prescription drug plan, then your next appeal would go to OMHA. This step in the process lets you explain your reasoning to an administrative law judge (ALJ). This ALJ hearing generally takes place over the phone. If you feel that an in person hearing is warranted, then you must show good cause to request it. To request an ALJ hearing, a minimum dollar amount must still be in dispute after the reconsideration phase. The ALJ adjudicator will decide the case and issue a disposition or ruling. The time frame typically takes about 90 days for the disposition after the judge has heard the case.

 

— Medicare Appeals Council

If you disagree with the ruling from the previous step, then you can file an appeal to the Medicare Appeals Council. Again, this is the next step regardless of which type of Medicare plan that you have. This council is part of the Department of Health and Human Services (HHS) Appeals Board. The council will generally decide the coverage determination at issue within 90 days of the appeals request. Unlike the previous step, there is no minimum dollar amount required to request an appeal at this level. The council might agree with the ALJ decision, or they could reverse or remand it. The council has broad discretion in their decision and how the case proceeds from here.

 

— Federal Court

The final appeal level is Federal District Court. If you disagree with the council’s decision, then you can petition the court to hear your appeal. A minimum dollar amount is again required at this stage. This appeal must be filed within 60 days of receipt of the council’s decision. Failure to strictly follow all the Federal court rules will almost always get your petition denied and your appeal dismissed. Appeals from all Medicare plans, even prescription drug coverage, could end up going to a Federal court judicial review.

 

How Long Do You Have To File An Appeal?

The answer depends on which stage of the process you are currently in. Initially, you should look at your Medicare Summary Notice (MSN) for the claim that you wish to appeal. It will have a date printed on it by which you must file your first level appeal. Generally, this date is 120 days from the date you received the initial determination. When appealing your Medicare coverage decision to the second level, you must file your appeal within 180 days of the redetermination notice receipt date. So, you basically have about 6 months to file from the date that the Level 1 appeal is decided.

Here, the timeframes for Medicare beneficiaries to appeal start to tighten a little. You only have 60 days to appeal to the OMHA from the reconsideration decision letter. Similarly, you have only 60 days to file a MAC appeal from the date of your OMHA decision or dismissal letter. Failure to meet these deadlines could cause you to lose your appeal. Finally, you must file your judicial review request with the Federal court no later than 60 days from the council’s decision. Deadlines in Federal court are taken extremely seriously, and failure to file on time will likely bar you from getting your appeal heard.

 

Tips For Winning Your Appeal

We know that you want to win your appeal or else you would not be filing it in the first place. There are some things that you should keep in mind when filing appeals with the Centers for Medicare & Medicaid Services. If you keep these tips in mind, it can greatly increase your odds of being successful. The first, and maybe one of the most important rules, is to always meet the deadlines. If you fail to meet a deadline to file your appeal, then it will almost always be grounds for a dismissal of your appeal.

Next, make sure that you use the proper forms when necessary and always present your evidence in a clear and concise manner. If new evidence has become available since your last level of appeal, then make sure that you show good cause why the evidence should be allowed in your next appeal. Use data and facts to clearly present your case, and try to refrain from stating your opinion unless specifically asked by the judge.

Finally, consider hiring an attorney if you feel that you cannot adequately navigate the appeals process on your own. Having an attorney or representative who is familiar with the rules and the process can be a huge advantage. They will know the filing deadlines as well as the evidence that will be required to win your appeal. Many attorneys will even offer you a consultation at no charge, so they can give you a rough idea of your odds of success should you decide to proceed with an appeal.

 

The Bottom Line

If you disagree with a decision by Medicare whether to cover a service or how much to pay, then you have a right to file an appeal. It could be nearly any decision that they make from whether to pay for care in a skilled nursing facility to whether a prescription drug is medically necessary. There are five levels of appeal with the final level going all the way to Federal court. Few appeals actually make it that far. There are things that you can do to increase your odds of winning like making sure you meet all the deadlines, having your evidence in order, and even hiring an attorney to represent you. If you feel that your Medicare claim has been improperly denied, then go ahead and file the first level of appeal to get the process started.

 

Frequently Asked Questions

 

How successful are Medicare appeals?

Medicare appeals are actually quite successful. In fact, data has shown that roughly 80% to 90% of appeals are won by the claimant who is appealing the decision. If you do not win your appeal at the first or second level, do not give up. Keep going as far in the appeals process as possible to increase your odds of ultimately winning your appeal.

 

How long does Medicare have to respond to an appeal?

It depends on which stage of the appeals process you are on. For Level 1, the general timeframe to respond to the appeal is 60 days. At level 2, the decision is again made within 60 days. If a decision cannot be reached in this timeframe, you will still receive notice of your rights in the appeals process. For level 3, OMHA has 90 days to come to a decision after the appeal has been heard. For level 4, the timeframe depends on how the case arrived, but it is generally 90 to 180 days. Finally, a level 5 appeal has no time limit. This means that the Federal Court can take as long as necessary to decide the disposition of the appeal.

 

What are the benefits of pursuing a Medicare appeal?

The benefits of pursuing an appeal are quite obvious. First, if you win the appeal, then Medicare will cover the item or service that was originally denied. This means that Medicare will pay for that health care service instead of you paying for it. In some cases, you might have already paid for the service. This means that Medicare will reimburse you for the payment that you have already made. Having Medicare pay for items that they should pay for will save you money and allow you to receive the treatments that you truly need.

 

What does a Medicare appeals officer review when they are making a decision?

At most levels of the appeal, the reviewing party will look at the evidence in the record. This means that they might review your medical records or medical history along with the contract terms of your health care plan. In some cases, they might ask a panel of physicians to review the evidence and make a determination regarding medical necessity of an item or service. This is why it is imperative to include as much evidence as possible at the first level of your appeal. It can be difficult to introduce new evidence later in the appeals process.

Elliot Marks

Elliot Marks

Elliot has spent years providing clear and concise information to help navigate the complex nuances of social security and many other government services in the United States. Elliot has a passion for helping those in need of these services to be able to find timely access to news and information that is relevant and helpful to their daily lives.