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Medicare Appeals Process

December 11, 2023

Medicare Appeals Process

Medicare provides excellent coverage for a wide variety of issues, but sometimes you may not agree with a coverage decision. 

Whether it’s a concern about a medical necessity, a decision about a type of medical equipment, or another reason for rejection, you might wonder if you have the option to state your case and confirm if Medicare may reconsider. 

The good news is that you have the right to appeal a decision. But what is a Medicare appeal? And how do you know how to win a Medicare appeal?

This guide will describe the Medicare appeals process and what you can expect in terms of timeframes and decision-making. We’ll also help clarify what evidence Medicare is looking for so you can have the best chance of winning your appeal.

Disagreeing with a decision can be frustrating, but there are steps you can take. Let’s take a look at them now.

What is a Medicare Appeal?

A Medicare appeal happens when coverage for a medical cost is denied, but you think it should be covered. You can also appeal if you feel that a reimbursement was not right, or that you paid too much for your portion of the medical costs.

If you feel that your health could be seriously harmed by waiting for a decision, you can request an expedited review. If the Medicare plan or doctor agrees, the plan must make a decision on your appeal within 72 hours. 

How to Appeal a Denied Medicare Claim?

If a claim is denied, you’ll receive a notification in the mail. This paperwork will include the service that was denied, the cost, and why Medicare will not cover the service.

Along with the letter, you’ll receive instructions on how to appeal the denied claim if you choose to do so. You’ll also have a deadline that you need to file by in order for the appeal to be considered
 

Medicare Appeals Process Flowchart

The appeals process can be easier to understand when you look at it in the form of a flow chart, which is available on CMS.gov. The flow chart shows five levels of Medicare appeals. 

When you look at the Medicare appeals process flowchart, you see that there is a standard process for both Part A and B, and then there is an expedited process available for certain Part A claims

After the second step, both appeals processes are the same. Let’s look at the five levels in more detail.

What Are the 5 Levels of Medicare Appeals?

There are five levels of medicare appeals. While it’s not necessary to exhaust all five levels of appeal when making your case, these levels show how and why you may choose to escalate your appeal if your answer is not satisfactory to you. 

  • Level 1: If a claim or request is denied, you can use the appeals information on the Medicare Summary Notice (MSN) to file your first appeal. You’ll need to file by the date on the MSN and use a Redetermination Request Form. This will be sent to the company handling the claim. Within 60 days, the Medicare Administrative Contractor (MAC) will let you know their decision. This is the first level of appeal.
  • Level 2: If you disagree with the decision made at Level 1, you can then escalate to Level 2. Level 2 involves having a Qualified Independent Contractor review your case. The instructions for how to do this will be listed in the decision letter you get from the MAC.
  • Level 3: If you’re still not satisfied with the decision and the amount in controversy (AIC) is $180 or more in 2022, you can elevate your case to Level 3, which is an Office of Medicare Hearing. The instructions for how to go about pursuing this hearing, and what information you need, are in the letter from the Qualified Independent Contractor. The AIC requirements change each year based on the medical care portion of the Consumer Price Index.
  • Level 4: If the hearing is still unsatisfactory, you can appeal to the Medicare Appeals Council, which is Level 4. You’ll receive information about how to do this from the Medicare Hearing. Within 90 days, you’ll get a decision from the Council.
  • Level 5: If you’re still unhappy and the AIC is more than $1,760 (in 2022), you can take the matter to a federal district court. This is Level 5 of the appeals process, and it’s the last option you have to resolve the dispute.

How long does Medicare have to deny a claim?

If you work with Medicare-approved doctors and providers, the claim will be filed electronically or on paper by your provider. You’ll be able to see the claim on your Medicare.gov account. Medicare usually settles claims in 14-30 days.

However, if there is a problem or concern with the claim, it may take longer to process. If there are errors and Medicare needs to get corrections, the claim can take months to process. This is usually worked out between the provider and Medicare.

If your claim is denied or you feel it isn’t processed correctly, you have a specific amount of time to appeal. If you don’t appeal on time, you lose your opportunity to have the issue reconsidered.

Why does Medicare deny claims?

Medicare denies claims for a variety of reasons. It may be a simple error by the provider, or you might have misunderstood what was covered by Medicare and how much was covered.

Some of the most common reasons claims are denied include:

  • Coding errors by the doctor’s office, like coding a Welcome to Medicare Visit as a normal checkup
  • No proof of medical necessity
  • Issues coordinating benefits with another health insurance plan you have
  • A claim for a service not covered by Medicare

For example, when you get Medicare coverage for a lift chair, only the lift device is covered by Medicare Part B. The chair itself is entirely your responsibility. If you didn’t realize that and expected reimbursement based on the full cost of the chair, you’d be disappointed when your reimbursement is less than you expect.

If Medicare denies a claim, do I have to pay?

If Medicare denies your initial claim, you’ll get a denial notice from Medicare. You’ll also receive a bill for the full cost of services from your medical provider.

Before you panic, however, keep in mind that you still have a right to appeal the denial. The first step is to look for why the claim was denied. If it was something simple like a coding error, contact your provider and have them resubmit the bill to Medicare with the right information.

If there’s something else going on, be sure to act quickly on your appeal. You’ll need information from your doctor to fill out the Redetermination Request Form and you only have a limited amount of time to file your appeal.

Even if you exhaust the appeals process and still have a bill from the provider, you may not have to pay. Legally, if you did not know or could not have been expected to know that Medicare would deny coverage, you may be able to get a waiver of liability. 

However, if you do not qualify for a waiver of liability, the cost is your full responsibility.

How to win a Medicare appeal

The best way to win a Medicare appeal is to make sure you have strong grounds for your position. Medicare approvals are run by human beings, and human beings make mistakes. Sometimes, simply pointing out that a service should be covered is enough to get a correction.

Here are some steps you can take to make your appeal as strong as possible:

  • Make sure your name, address, and Medicare number are listed on all of your appeal documents
  • Include a letter explaining why the service should be covered, being sure to address the listed cause for denial
  • Circle the items you disagree with on the MSN, or list them specifically in your appeal letter
  • Get a letter of support from your healthcare provider explaining why the service was medically necessary
  • Make sure you file your appeal by the deadline, which can be as little as 60 days from the denial notice

Many people who appeal are granted at least some additional coverage, so it’s worth your time if you feel that you have a strong case.

How long do I have to file a Medicare appeal?

The amount of time you have to file your appeal will be included in the letter notifying you of coverage being denied. The timeframe will be between 60 and 120 days from the date on the letter.

The appeals process for Original Medicare and Medicare Advantage looks slightly different in the beginning because for Level 1, the Advantage provider reviews your case inside the company. However, from Level 2 onward, the reviews are conducted by independent evaluators outside the company.

How long does a Medicare appeal take?

Each part of the Medicare appeals process can take some time. From the time that your appeal request is received, the reviewer has 60 days to make a decision for Level 1 and Level 2 appeals.

For a Level 3 or Level 4 appeal, Medicare has 90 days to render a decision. A Level 5 appeal takes place in court, and the decision of the court is the final determination of your case.

You also need to take into account how long you take to file at each appeal level. As you can see, the time for the appeals process adds up if you go all the way through Level 5.

Who handles medicare appeals?

The group that handles appeals for Medicare Advantage changes depending on which appeal level you are considering. For a Level 1 appeal with Medicare Advantage, your original coverage provider has the opportunity to reconsider their decision.

Both Original Medicare and Medicare Advantage Level 2 decisions are made by Qualified Independent Contractors. Level 3 appeals are decided by the Office of Medicare Hearings and Appeals. Level 4 appeals are heard by the Medicare Appeals Council, and Level 5 appeals are determined by the federal district court.

The multiple decision-makers help avoid problems with bias within specific organizations and help ensure that all Medicare beneficiaries are treated fairly.

Learn More About the Medicare Appeal Process

Many people find that Medicare appeals help them get the additional coverage they deserve. However, appealing without a solid foundation for your case will not get you what you’re hoping for. It’s important to understand what Medicare covers and at what levels before you file an appeal.
One of the important parts of getting the coverage you deserve is having the right Medicare insurance plan. If you have questions about your plan or want help comparing plan options, we’re here for you. Contact us today!

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