Q: Medicare denied payment for services I recently had and indicated I could appeal the decision. How do I start this process?
A: Denial of payment for services can occur for many reasons. Before starting the appeal process it would be wise to talk with the provider’s office to see if the problem is due to something as simple as a billing error. If so, ask that the billing be corrected and the bill resubmitted to Medicare for payment.
However, if that is not the cause of the denial then you should start the appeal process. About half of all appeals are successful, so it is worth doing.
If your health care coverage is from original Medicare then your appeal process is made directly to Medicare. Medicare’s process consists of five levels: request for redetermination, request for reconsideration, hearing before an administrative judge, submitting a claim to appeals counsel review and judicial review in U. S. District Court.
Your request for determination starts with a review of your Medicare Summary Notice. The MSN lists all of the services, supplies and equipment billed to Medicare, for a specific period of time, for your care.
Each entry will show you who provided the service, the amount billed, the amount Medicare approved, the amount Medicare paid and the amount you may be responsible for. This entry will be followed by a letter or letters. These letters will appear again at the end of the MSN with an explanation about the outcome of that claim.
After receiving a denial of a claim you have 120 days to request a redetermination by a Medicare contractor who will review your claim and issue a response. You can request a redetermination by using your MSN. Circle the items you are disputing and provide an explanation of why you believe the decision should be reversed. Attach any supporting documents you have explaining your reasoning for the request.
Keep a copy of the MSN and any supporting documents for your file and send the copy to the address on the MSN.
You should hear back within 60 days. If your request is denied again you can request a reconsideration from a different claims reviewer. The instructions for requesting a reconsideration will be included on the returned form.
A denial at the reconsideration level ends the process unless the charges in question are at least $150. If they are at least $150 you can request a hearing with an administrative judge. If you are denied at this level you can submit a claim to the Appeals Council Review.
The final appeal would be heard before a U.S. District Court and the claim must be for at least $1,460.
If your denial is with a Senior Advantage Plan the process is slightly different. You must file your appeal within 60 days of the denial and you must direct your appeal to the plan you are enrolled in and follow the plan’s instructions.
If your denial is with your Part D Prescription Drug Plan you have 60 days from the date of denial notice and you must deal directly with the drug plan in which you are enrolled.
Part D Plans also have 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 7 days.
For more information on the Medicare appeal process visit Medicare.gov or call 800-633-4227 and request a copy of Medicare Appeals publication No. 11525. You can also read this information on line at medicare.gov/pubs/pdf/11525.pdf.
Hope this gives you what you need to know to start your appeal process.
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