If you’ve decided to appeal a Medicare coverage decision, you’ll need to provide the rationale for why the company should reconsider. That means you’ll need to write a letter explaining your case.
While you might feel intimidated by the prospect of writing a Medicare appeal letter, remember that this is simply your opportunity to present the reasons why your claim should be covered. Medicare decisions are made by humans, just like us, and humans sometimes make mistakes. By creating a strong appeal letter, you’ll maximize your chances of getting additional Medicare coverage.
Keep reading to learn more about writing a successful appeal letter!
As you get ready to write a Medicare appeal letter, there are certain things you should be sure to include. For example, you need to have your name, address, and Medicare number on all of your correspondence about your claim.
Some other important elements of the letter include:
You’ll also need to make sure you get the appeal filed by the deadline, which can be 60-120 days from the date you receive the MSN.
Don’t be afraid to write a few drafts before you settle on your final explanation. You can also try explaining your case to a friend or family member in order to get feedback on how to more clearly articulate exactly what you’re disputing and why.
Once you receive a decision on your initial appeal, you can decide whether to continue appealing your case.
You can find a variety of Medicare appeal letter examples online. Having a Medicare appeal letter example can help you format your letter to be easily understandable and concise, which can help you get a better outcome.
A sample of a Medicare appeal letter l can be found on Great Sample Resume. You’ll notice that the letter immediately states that this is an appeal of a particular claim number for services on a specific date. The letter then states the reason for denial and explains why this reason is not valid in this specific case.
This particular letter example is based on a coding error. In many cases, you don’t have to write a Medicare Appeal Letter for a coding error — you can simply have the provider resubmit the claim with the correct code.
The University of Rochester Medical Center has another example of a Medicare Appeal Letter. In this case, it starts off by immediately stating who is writing and what service was denied. Then, the letter explains that the service was medically necessary for a specific condition.
If you have an Evidence of Coverage document that shows that the denied service should have been covered, that’s strong evidence in your favor. You can also include doctor’s letters supporting the fact that the service was medically necessary. Finally, you can also send copies of the appeal to relevant individuals within your provider team.
Here's a template for your own Medicare appeal letter. Please remember to customize it with your specific information and details.
[Your Name] [Your Address] [City, State, ZIP Code] [Date]
[Medicare Administrative Contractor Name] [Medicare Administrative Contractor Address] [City, State, ZIP Code]
Re: [Your Medicare Number] [Date of Medicare Decision] [Explanation of Decision]
I am writing to appeal the recent decision made by Medicare regarding my [specific service or item] claim, which was denied on [Date of Medicare Decision]. I appreciate the prompt response I received, but I believe that there has been an error in the decision. I would like to request a review and reconsideration of this denial.
I would like to provide the following information in support of my appeal:
Details of the Service/Item:
Reason for Appeal: I believe the denial of coverage for [specific service or item] was incorrect because [provide a brief explanation of why you believe the denial was incorrect, such as medical necessity, supporting documentation, or other relevant information].
Supporting Documentation: Please find attached the following documents:
Request for Review: I kindly request that you review my appeal and reconsider the decision made. I believe that the information provided supports the medical necessity of the [specific service or item] and the coverage should be approved.
I appreciate your prompt attention to this matter. Please inform me of the status and outcome of this appeal as soon as possible. If you require any additional information or documentation, please do not hesitate to contact me.
Thank you for your time and consideration.
[Your Typed Name]
Enclosures: [List the attachments you are including]
Please ensure that you personalize this letter with your specific information and circumstances. Additionally, follow the specific appeal process and guidelines provided by your Medicare Administrative Contractor for the best chance of a successful appeal.
As you can see, there are a variety of ways to approach an appeal letter. The key is to be very clear about what claim you’re discussing, the date of services, and why you feel that the denial was a mistake.
Appealing a denied claim can help you get additional coverage. As long as you have a strong case as to why the denial was an error, you can appeal and get a reconsideration. There are five levels of the appeal process overall if you still find yourself to be unhappy with the outcome.
If you have questions about your Medicare coverage or would like to compare the various plans available to you, it can be helpful to talk to a licensed agent. We’d love to talk to you about your plan and your options to ensure you get the right coverage for your needs. Contact us today!
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