But before going that route, talk with the doctor, hospital and Medicare to see if you can spot the problem and resubmit the claim. Some denials are caused by simple billing code errors by the doctor’s office or hospital. If, however, that doesn’t fix the problem, here’s how you appeal.
ORIGINAL MEDICARE APPEALS
If you have original Medicare, start with your quarterly Medicare Summary Notice. This statement will list all the services, supplies and equipment billed to Medicare for your medical treatment, and will tell you why a claim was denied.
There are five levels of appeals for original Medicare, although you can initiate a fast-track consideration for ongoing care, such as rehabilitation. Most people have to go through several levels to get a denial overturned.
You have 120 days after receiving the notice to request a “redetermination” by a Medicare contractor, who reviews the claim. Circle the items you’re disputing on the notice, provide an explanation of why you believe the denial should be reversed, and include any supporting documents like a letter from the doctor or hospital explaining why the charge should be covered. Then send it to the address on the form.
The contractor will usually decide within 60 days after receiving your request. If your request is denied, you can request for “reconsideration” from a different claims reviewer and submit additional evidence.
A denial at this level ends the matter, unless the charges in dispute are at least $140. In that case, you can request a hearing with an administrative law judge. The hearing is usually held by videoconference or teleconference.
If you have to go to the next level, you can submit the claim to the appeals council review. Then, for claims of at least $1,400, the final level of appeals is judicial review in U.S. district court.
ADVANTAGE, PART D APPEALS
If you’re enrolled in a Medicare Advantage or Part D prescription drug plan the appeals process is slightly different. One difference is that you have only 60 days from the date on the denial notice to file an appeal. And in both cases, you start by appealing directly to the plan, rather than to Medicare. Follow the plan’s instructions on its explanation of benefits.
Part D has a fast-track appeal of 72 hours if you haven’t received your medication and waiting would jeopardize your health. Otherwise, the plan must notify you of its decision within seven days.
For more information, along with step-by-step procedures on how to make an appeal, visit medicare.gov and click on the “Claims & Appeals” tab at the top of the page, or call Medicare at 800-633-4227 and request a copy of publication No. 11525 “Medicare Appeals.” You can also read it online at medicare.gov/pubs/pdf/11525.pdf.
If you need some help, contact your State Health Insurance Assistance Program (SHIP), which has counselors that can help you understand the billing process and even file your appeal for you for free. To locate your local SHIP, visit shiptalk.org or call the Eldercare Locator at 800-677-1116. The Medicare Rights Center also offers free phone counseling at 800-333-4114.