June 2019: Original Medicare and Medicare Advantage Standard Appeals

What can I do if I get a denial for a health care service or item?

If you receive a denial from Original Medicare or your Medicare health or drug plan, you have the right to appeal. An appeal is a formal request for review of a decision made by your Original Medicare, Medicare Advantage, or Part D plan. If you were denied coverage for a health service or item, you may appeal the decision.

Before you start any appeal, make sure you fully read all the letters and notices sent by Medicare and/or your plan. Call 1-800-MEDICARE or your private health or drug plan to learn why your coverage is being denied, if the information was not provided.

There is more than one level of appeal, and you have the right to continue appealing if you are not successful at the first level. Be aware that at each level, there is a separate timeframe for when you must file the appeal and when you will receive a decision. Make sure to file each appeal in a timely manner. If there is a reason you cannot submit your appeal within the timeframe, see whether you are eligible for a good cause extension. Otherwise, your appeal may not be considered.

A standard appeal is an appeal of a denial for a health care service, item, or prescription drug that is covered by Medicare Part A or B. Keep in mind that you will follow a different appeals process if you are appealing the denial of a Part D-covered prescription drug or if you disagree with a hospital or skilled nursing facility’s decision to discharge you or with a home health agency’s or hospice’s decision to end your care.

When should I file a grievance instead of an appeal?

If you are dissatisfied with your Medicare Advantage or Part D prescription drug plan for any reason, you can choose to file a grievance. A grievance is a formal complaint that you file with your plan. It is not an appeal. Times when you may wish to file a grievance include if your plan has poor customer service or you face administrative problems (such as the plan taking too long to file your appeal or failing to deliver a promised refund). In some cases, you may want to file both an appeal and a grievance. To file a grievance, send a letter to your plan’s Grievances and Appeals Department. Check your plan’s website or contact them by phone for the address.

How can I appeal a denial by Original Medicare?

If you are denied coverage for a health service or item before you receive it, you will need to get an official written decision from your plan, called a Notice of Denial of Medical Coverage. You can start your appeal by following the instructions on the Notice of Denial of Medical Coverage. Make sure to file your appeal within 60 days of the date on this notice. You will need to send a letter to your plan explaining why you need the service or item. You may also want to ask your doctor to write a letter of support. Your plan should make a decision within 30 days.

If your plan denies coverage for a service or item you have already received, you should receive a written notice from your plan stating that it is not covering the service or item. This can either be an Explanation of Benefits (EOB) or a Notice of Denial of Payment. This is not a bill. Start your appeal by following the instructions on this notice. Send a letter explaining why you need the service or item, and ask your doctor to write a letter of support. File your appeal within 60 days of the notice you receive from your plan. Your plan should make a decision within 60 days.

In either case, If your appeal is successful, your service or item will be covered. If your appeal is denied, you can move on to further levels of appeal

How can I appeal a denial by my Medicare Advantage Plan?

To find out if Original Medicare has covered or denied the health care services you have received, check your Medicare Summary Notice (MSN). The MSN is a summary of health care services and items you have received during the previous three months.

If your MSN says that Medicare did not pay for a services, and you think that it should, call your doctor to make sure that there was not a billing error before appealing. To start your appeal, you should follow the instructions listed on your MSN or Redetermination Request form. This includes circling the denied service listed and filling out the shaded section at the end of the MSN. Send your appeal to the Medicare Administrative Contractor (MAC), using the name and address listed on the shaded section of your MSN, within 120 days of the date on your MSN. The MAC should make a decision within 60 days. If your appeal is successful, your service or item will be covered. If you appeal is denied, you can move on to further levels of appeal.

 


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