What You Need to Know About Filing a Medicare Appeal

Have you recently been denied a service you feel should have been covered?
Here is what you need to know about filing an appeal:

If you are covered under Medicare, you have the right to file an appeal if you disagree with your plan’s decision not to cover a prescription or service. An appeal is not to be confused with a compliant or grievance, which is filed when you are dissatisfied with the quality of care you receive. Depending on whether your disagreement is with Original Medicare, or your Medicare health plan, will determine who you file your appeal with, and which forms you will need.

Appeals concerning Original Medicare must be filed by the date in your Medicare Summary Notice (MSN). The MSN is a notice Original Medicare sends out to its beneficiaries every three months that lists all services and supplies billed to Medicare during that time. Make sure to complete a “Redetermination Request Form [PDF, 100 KB]” and send it to the claims address listed in your MSN. You may also send a written request to the company that handles claims for Medicare, but be sure to include the following information:

• Your name, address, and the Medicare Number on your Medicare Card.
• Circle the items and/or services you disagree with on the MSN. Or list the specific items and/or services for which you are requesting a redetermination, and the dates of service.
• An explanation of why you think the items and/or services should be covered.
• The name of your representative if you have appointed a representative.
• Any other information that may help your case.

You should receive a response generally within 60 days of your request. If Medicare decides to grant your request, you will see the change listed on your next MSN.

If you have a Medicare Health plan, you must contact your plan to file your appeal within 60 days from the date the coverage decision was made. Be sure to include the following information in your request:

• Your name, address, and the Medicare Number on your Medicare Card
• The items or services for which you are requesting a reconsideration, the dates of service, and the reason(s) why you are appealing.
• The name of your representative and proof of representation if you have appointed a representative.
• Any other information that may help your case.

You may ask for an expedited decision if you believe your health is in danger by waiting longer for a determination. In this instance, the plan must give you its decision within 72 hours if they or your doctor determines your health is in jeopardy. The plan has 30 calendar days to respond to standard service requests, and 60 calendar days to respond to payment requests.

Appeals for Medicare Prescription Drug plans must also be made through the plan. To file an appeal for drugs which you have already purchased, you or your prescriber must submit your request in writing or send the plan a “Model Coverage Determination Request” form. If you are appealing drugs that you have not received yet, you or your prescriber can ask for a coverage determination or an exception. To ask for a coverage determination or exception, you can do one of these:

• Send a completed “Model Coverage Determination Request” form.
• Write your plan a letter.
• Call your plan.
• If you are asking for an exception, your prescriber must provide a statement explaining the medical reason why the exception should be approved.

You may ask for an expedited decision if you believe your health is in danger by waiting longer for a determination. In this instance, the plan must give you its decision within 24 hours if they or your doctor determines your health is in jeopardy. Your Medicare Drug plan has 72 hours to respond to standard service requests and 14 calendar days to respond to payment requests.

Furthermore, if you have coverage through Programs of All-inclusive Care for the Elderly (PACE), the PACE organization must inform you of your rights and instruct you how to appeal in writing. People who are in a PACE program have different appeal rights.

If you have a Medicare Special Needs Plan (SNP), the plan must notify you in writing on how to submit an appeal. Once the appeal has been submitted, the plan will review the original decision. Should the plan deny the appeal, an outside organization appointed by Medicare will review its decision.

Regardless of the type of plan you have, be sure to keep any notices and information you have regarding the appeal in question. If you need help filing an appeal, you may be able to get free assistance through your State Health Insurance Assistance Program (SHIP). Filing an appeal can seem daunting, but it may be worthwhile if you are in dire need of a prescription or service that you feel should be covered. Do not hesitate to advocate for your health, after all you have the right to appeal.

Call 1-800-334-9330 and one of AMAC’s trusted, licensed Advisors will be happy to assist you with your needs