Each year, 10% of Medicare beneficiaries have claims denied, according to a KFF survey conducted over the past 12 months. These claims are for care that they expected to be covered, but were not, forcing beneficiaries to file an appeal.
The good news is that if Medicare denies a request for coverage, you have the right to appeal that decision. The biggest problem is the beneficiaries’ lack of knowledge about their right to appeal.
The same survey reported that 69% of consumers whose claims had been rejected did not know they could appeal those decisions, and a large majority (85%) do not file appeals, leaving the case unresolved.
When to Consider Appealing a Medicare Denied Claim
Before starting the process, it is essential to consider whether your appeal is viable. Each person’s situation is different. It is worth appealing if you really believe you have a significant medical need, or that you will be at risk if you are discharged earlier than you think is appropriate, or if you need specific care or treatment.
It is highly recommended to have a conversation with the doctor who provided the service. Ask if the doctor believes the treatment is necessary and if he or she is willing to write a letter to include in the appeal with additional information that can help argue your case. This letter is crucial to the potential success of the appeal.
Medicare Appeals Can Be Intimidating: Don’t Get carried away
Medicare appeals can seem intimidating and complicated. According to an analysis of call data, 29% of calls in 2022 to the Medicare Rights Center’s national helpline were about denials and appeals. The toll-free phone line (800-333-4114) helps people with questions about Medicare. The center receives 20,000 calls a year and is open Monday through Friday, 9 a.m. to 3 p.m. Eastern Time.
Certain types of Medicare coverage denials are more common than others, explains Sarah Murdoch, director of client services at the Medicare Rights Center, who also runs the help line mentioned above.
Annual Services
A common denial occurs when your plan covers an annual service and it appears that you received the service more than once in that year. For example, if you had a mammogram in January and everything was clear, but you found a lump 10 months later and needed more testing, the coding would have to be different than the annual mammogram. If not, your claim may be denied, even if the procedure is medically necessary.
Prescription drugs
Another typical denial concerns the quantity of medications prescribed. For example, if you are prescribed 60 pills, but the plan only covers 30 each month, you may feel obligated to appeal to have the rest covered.
Hospital Stays
Hospital stays may also be grounds for appeal due to high costs and co-pays. If a person is considered an inpatient, they may be eligible for rehabilitation days under Medicare. However, if the person is “under observation” during part of their hospital stay, they may not be eligible for Medicare rehabilitation coverage.
What is an Immediate or Expedited Appeal?
If you think you are being discharged from hospital too quickly, you have the right to request an immediate review. This may allow for improved care and a more accurate assessment of your need for hospitalization. While your case is being reviewed, you can stay in the hospital free of charge.
You can also get an expedited appeal if you disagree with the decision that you no longer need the services of a home health agency, outpatient rehabilitation center, or skilled nursing facility.
How to File an Appeal if You Have Original Medicare
Steps to Appeal a Denied Claim
- Receive the Medicare Summary Notice (MSN): Once you receive the MSN in the mail indicating that you were denied coverage, you have 120 days to file an appeal.
- Complete the Redetermination Request Form: Send the form to the company that handles Medicare claims (the Medicare administrative contractor).
- Include Necessary Information:
- Your name, address, and the Medicare number on your card.
- A list of the items and/or services that you do not agree with on the MSN.
- An explanation of why you think the items and/or services should be covered. Include a letter from your doctor, on letterhead, explaining why they should be covered.
- The name of your representative, if you have designated one.
- Any additional information that may help your case.
- Wait for a Decision: Expect a decision within 60 days after the Medicare administrative contractor receives your request. If Medicare agrees to cover the item or service, it will appear on your next MSN.
How to File an Appeal if You Have Medicare Advantage
Request Reconsideration
Once you receive notice of a denied claim, you can appeal the decision by requesting reconsideration and include the same information you would use to appeal a claim under original Medicare.
Standard or Accelerated Reconsideration
You, a representative, or your doctor can request a standard or expedited reconsideration. If your doctor requests expedited reconsideration, plans must expedite the request. Requests for reconsideration must be submitted to the health plan within 60 calendar days from the date of the denial notice.
Standard requests are usually required in writing, although some plans may accept verbal requests. Check the Evidence of Coverage your plan sends you each year to see if your plan accepts verbal requests. Expedited requests can be made verbally or in writing.
Plan Response Times
Once the plan receives a reconsideration request, it must respond within 72 hours for expedited requests, 30 calendar days for standard requests, or 60 calendar days for payment requests.
How to File an Appeal if You Have Medicare Part D (Prescription Drug Plan)
Appeal Process
The appeal process varies depending on whether you have already purchased the medications or not.
Drug Reimbursement Appeal
If you already purchased the drugs and want your money back, you or your prescribing doctor must make the standard request in writing, via a letter or a completed Coverage Determination Request form.
Appeal for New Prescription Coverage
If you want coverage for a prescription you have not yet received, you or your doctor can request a coverage determination or exception. You can make your request in writing, through a letter or a completed sample Coverage Determination Request form, or by calling your plan.
If you request an exception, your prescribing doctor must provide a statement detailing the medical reason why the exception should be approved. You can request an expedited request if your plan or your doctor determines that waiting for a standard response could seriously jeopardize your health, life, or ability to regain maximum function.
Response Times for Each Type of Request
- Expedited application: 24 hours.
- Standard service request: 72 hours.
- Payment request: 14 calendar days.
Additional Appeal Requests
If you do not receive a favorable decision on your first appeal, you can continue to appeal the decision. Medicare Advantage and Medicare Part D offer expedited responses at certain levels, but all of these review levels are available to original Medicare, Medicare Advantage, and Medicare Part D beneficiaries:
- Level 1: The original appeal request as described above.
- Level 2: A review by a “qualified independent contractor.”
- Level 3: A review and decision by the Medicare Office of Hearings and Appeals.
- Level 4: A review by an appeals board.
- Level 5: A judicial review by a federal district court.
At each level of the appeals process, you must be given additional information about how you can appeal the decision to the next level if you disagree with the decision provided in Levels 1 through 4. Each level of review may require a minimum dollar amount for the benefit being appealed.
