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How Do I File a Medicare Appeal?
By Donna Frederick
After retiring from a career as an executive travel counselor in 2006, Donna Frederick embarked on a second career as a licensed insurance agent. During that first year, many clients told Donna how ov ...erwhelmed they felt by Medicare, but that her assistance helped them finally understand the Medicare program. That experience inspired Donna to focus her efforts on educating her clients to ensure they fully understand their Medicare options. Today, Donna takes pride in providing outstanding customer service and going the extra mile to make sure each client knows all of their options and has a sound understanding of their Medicare plan, from costs to coverage and all points in between.Read more
Mar 04, 2021
If you disagree with a coverage decision from either the Medicare program or your Medicare health plan, you have the right to file an appeal. This article explains the Medicare appeal process and provides tips for winning your claim.
Who Can File a Medicare Appeal?
You have Medicare appeal rights whether you have:
- Original Medicare (Medicare Parts A and B)
- A Medicare Part C plan, more commonly known as Medicare Advantage
- A Medicare Part D prescription drug plan
- Coverage through Programs of All-inclusive Care for the Elderly, or PACE
- A Special Needs Plan (SNP)
When Can You File a Medicare Appeal?
You may file a Medicare appeal if you disagree with Medicare's decision (or your Medicare plan's decision) regarding one of the following requests:
- A healthcare service, item, prescription, or supply that you believe should be covered
- Payment for a healthcare service, item, prescription, or supply that you already received
- To change your out-of-pocket cost for a healthcare service, item, prescription, or supply
You may also file an appeal if the Medicare program or your Medicare insurance plan refuses or reduces continuing coverage for a healthcare service, item, prescription, or supply you were receiving.
Can You Appoint a Representative?
You may appoint another person to serve as your representative in the appeal. Your representative may be anyone you choose, including your doctor, a family member, friend, or an attorney.
The easiest way to appoint a representative is to complete and submit the Appointment of a Representative form (CMS-1696). Just follow the instructions included with the form.
Your second option is to submit a written request that includes the following information:
- Your name, Medicare ID number, address, and phone number
- A statement that you are appointing someone else as your representative AND that you authorize the release of your personal and identifiable health information to said representative
- Your representative's name, address, and phone number
- Your relationship to your representative AND your representative's profession, if your relationship is in a professional capacity (i.e., a doctor or attorney)
- An explanation of why this person is representing you and to what extent
You may also talk to your State Health Insurance Assistance Program (SHIP) for assistance in filing your appeal.
Can your doctor file an appeal without being appointed as a representative?
If you have a Medicare health plan (including Advantage, Part D, PACE, and SNP), your doctor may request first-level appeals, such as a pre-service reconsideration, or request a coverage determination without being appointed as a representative. However, if the appeal goes to the next level and you still want your provider to represent you, you must submit the Appointment of Representation form.
Filing an Appeal if You Have Original Medicare
Original Medicare includes:
- Hospital insurance, aka Medicare Part A, which covers inpatient care received in a hospital or skilled nursing facility (SNF)
- Medical insurance, aka Medicare Part B, which covers outpatient services like doctor visits, lab work, and mental health care
Every 3 months, Medicare beneficiaries receive a Medicare Summary Notice (MSN) that details the healthcare services and items received in the previous quarter. You may receive the MSN via U.S. mail or electronically through your MyMedicare.gov account. (Click here to create an account if you don't already have one.)
The Medicare Summary Notice explains what Medicare covered and paid during the 3-month period, as well as whether you owe anything out-of-pocket to your healthcare providers. It also shows any claims decisions, known as the "initial determination" as per the Medicare Administrative Contractor (MAC). This is the independent contractor that handles Medicare claims.
If you received a healthcare service or item that is not listed on the MSN, ask your healthcare supplier or provider for an itemized statement to see whether they billed Medicare yet. If not, providers have up to one year to submit claims to Medicare.
Review the Summary Notice carefully to understand any coverage decisions. If you want to file an appeal, instructions are included with the MSN. Ask any relevant healthcare providers to supply information that will help support your claim and keep copies of everything you send to Medicare.
The Appeals Process with Original Medicare
There are five possible levels to the Medicare appeals process. Your claim will not necessarily go through all five levels.
Level 1: Redetermination by the Medicare Administrative Contractor
If you disagree with the initial coverage decision listed on the Medicare Summary Notice, you may request a redetermination. You have 120 days from receipt of the MSN to make your request. Appeal instructions include:
- Circle the decisions listed on the MSN that you disagree with and add your name, phone number, and Medicare number
- On a separate sheet of paper, provide a written explanation of why you disagree with the decision and attach it to the MSN
- Attach any documentation you receive from your Medicare provider, adding your Medicare number to all documents (don't forget to keep copies of everything for your records)
Send your packet to the MAC address listed on the Medicare Summary Notice, under the "File an Appeal in Writing" section. Include the name of your representative, if applicable.
You may also download, complete, and submit CMS-20027: Medicare Redetermination Request Form. If you don't have access to a printer, you may call 1-800-MEDICARE (633-4227) or TTY 1-877-486-2048 to request any form listed on this page.
The Medicare Administrative Contractor should notify you of their decision within 60 days. If you send supporting documentation after filing your request for redetermination, it may take longer than 60 days.
Level 2: Reconsideration by a Qualified Independent Contractor
If you disagree with the MAC decision from Level 1, you have 180 days to file your Level 2 request. Instructions on filing are included in the Medicare Redetermination Notice you received in the previous level.
The Redetermination Notice includes a copy of CMS-20033: Medicare Reconsideration Request Form. If not, either download it or call Medicare. Or, you may also file a written request as detailed in Level 1. Again, get any supporting documentation you can from your healthcare providers and suppliers, including your Medicare number on all documents and saving copies for your records. Add the date of the Level 1 decision.
The Qualified Independent Contractor (QIC) assigned to your claim will also receive all information provided in Level 1. You should receive a decision within 60 days.
Level 3: Decision by the Office of Medicare Hearings and Appeals
If you disagree with the QIC decision AND the amount your claim exceeds $180 in 2021, you have 60 days to request a decision from the Office of Medicare Hearings and Appeals (OMHA). This level may require you to attend a hearing before an Administrative Law Judge (ALJ), during which you will explain the reason for your appeal. Typically, this occurs over the telephone or via video call. However, an in-person hearing may be ordered.
You may also request the ALJ simply review the appeal record to date. If the ALJ feels that the information in the appeal record supports your case, they'll rule without a live hearing.
If you have multiple appeal claims, you may be able to meet the $180 requirement by combining them.
To file your Level 3 appeal, complete the "Request for Administrative Law Judge (ALJ) Hearing or Review of Dismissal" (OMHA-100). Unlike the previous levels, this form comes from the Department of Health and Human Services. You may also submit a written request following the instructions included in Level 1. Don't forget to include the dates of previous decisions.
If you want to request the review without going through a hearing, you must also submit ONE of the following:
- Form OMHA-104: Waiver of Right to an Administrative Law Judge Hearing (the OMHA-100 link above takes you to the same page)
- A written statement that you do not wish to have an in-person, phone, or video teleconference and the reason you choose to waive this right
Please note that, even if you request a hearing waiver, one may be required if someone else mentioned in your claim (such as a healthcare provider) does not provide the same waiver.
Level 4: Review by the Appeals Council
If you disagree with the OMHA decision, you have 60 days to request a review by the Appeals Council (there is no minimum claim amount requirement for Level 4).
To file this request, simply follow the instructions included with the Level 3 decision. Start by completing Form DAB-101: Request for Review of Administrative Law Judge Medicare Decision/Dismissal. You may also file a written request, following the same instructions listed above.
If the reason for your request is that OMHA did not issue a timely decision, send your completed form to the OMHA address you received with the QIC decision. You may also send it to the OMHA office where your request is still pending.
Don't forget to add the dates of each decision. And, as always, keep copies of everything included with your appeal.
Level 5: Judicial Review by a Federal District Court
If you disagree with the Appeals Council's decision AND your claim is for at least $1,760 (in 2021), you may follow the instructions included with the Level 4 decision to request a Judicial Review by a Federal District Court.
Filing an Appeal with Medicare Advantage or Part D
If you wish to appeal a coverage decision and you have a Medicare Advantage plan and/or prescription drug coverage through Part D, the steps are the same as if you have Original Medicare with one exception. The first level of appeal is filed directly with the insurance company that provides your plan. To do this, contact your plan provider and follow its guidelines for filing an appeal.
Filing an Expedited Appeal
Some Medicare beneficiaries need the appeals process to move more quickly. This typically occurs when you believe services are ending too soon and you are in a:
- Skilled nursing facility
- Comprehensive outpatient rehabilitation facility
It may also be required if you receive hospice services.
Requesting a fast appeal in a hospital
If you believe you're being discharged too quickly from a Medicare-approved inpatient stay, you have the right to file an expedited appeal.
Two days after being admitted as a hospital inpatient, you should receive an "Important Message from Medicare" explaining your Medicare rights. (Ask the hospital staff for a copy if you have not received it yet.)
Also known as IM, this notification includes contact information for the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO).
If you are discharged more than 2 days after receiving the IM, the hospital must give you either a copy of the original or a new one. Both must be signed by you before being discharged.
You must request a fast appeal from the BFCC-QIO no later than the day you're scheduled to be discharged. In other words, you cannot file an expedited appeal after being discharged.
To file your appeal, simply follow the instructions on the Important Message from Medicare. The BFCC-QIO will notify the hospital that you've appealed the discharge order. The hospital will respond by giving you the "Detailed Notice of Discharge" that explains why your healthcare services are no longer considered reasonable and necessary as well as any other applicable information. The BFCC-QIO will issue its decision within one day of receiving the information it requests.
If the BFCC-QIO finds in your favor, Medicare will continue covering your hospital stay as long as it's considered medically necessary. You will still owe any applicable coinsurance and deductibles. If the BFCC-QIO agrees with the hospital, you will not be responsible for any additional charges (besides the applicable deductibles and coinsurance) until 12:00 noon on the day after you receive the BFCC-QIO decision.
Filing an expedited appeal in other settings
If you're receiving Medicare-covered healthcare services in a non-hospital setting (e.g., skilled nursing facility or hospice care), you should get a "Notice of Medicare Non-Coverage" at least 2 days before said coverage ends.
This notification includes instructions on how to file a fast appeal, including contact information for the BFCC-QIO.
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