Whether it’s through the Medicare program or a certified Medicare insurance plan provider, there’s always a chance your request for coverage of a claim may be denied.

If you disagree, you may be able to appeal the decision. An appeal is the process that a Medicare insurance beneficiary can use to request the Medicare program or their plan’s provider revisit their claim.

What Can I Appeal?

Not every coverage or payment decision can be appealed. Generally, you can only appeal if your claim or request fits one of the following circumstances:

  • You still need the service, supply, item, or prescription that the Medicare program or your plan has previously provided or fully or partially funded.
  • You feel that your plan should cover the health care service, item, or prescription drug.
  • You were previously covered for the health care service, item, or prescription drug.
  • Your claim was a change in the amount that you must pay for the health care service, the item, or prescription drug.

You may also be able to appeal if you have a Medicare Medical Savings Account (MSA) Plan. In this instance, you must have met your plan’s deductible or believe that the requested services or items should count towards the deductible.

What Are the Steps to Appeal?

Medicare Advantage

If you have a Medicare Advantage plan, you have the right to request payment for items or services you think should be covered, provided, or continued. Your initial request for an appeal is called an “organization determination.” You, your representative, or your physician may request an organization determination in advance as well. You do this to ensure that a service or item is covered.

If your plan chooses to not cover your request, they’re required to notify you of this decision. This notice will explain why your request was denied as well as include instructions on how to appeal that plan’s decision. This is also a part of the organization determination step. If you disagree with the reasons outlined in the notice, you have the right to move your appeal to the next step in the process, laid out below.

Original Medicare

Every three months you’ll receive a “Medicare Summary Notice” (MSN) outlining what Medicare paid and what you may owe the provider or supplier. This is considered the initial determination and is processed by the Medicare Administrative Contractor. If you disagree with a Medicare program payment decision, you can choose to appeal that claim. Since you don’t have a private health plan, you would start with the five-step process outlined below.

No matter if you receive coverage from Original Medicare or a certified Medicare insurance plan provider, there are a few things you should take care of once you decide to make an appeal. Your first action should be to read your Medicare insurance plan to learn about your appeal rights. If you can’t find your appeal rights, locate your plan’s contact information, which you can usually find on your plan’s membership card.

Next, contact your primary care physician, your health care provider, or prescription drug supplier. Ask them for any information that may help your appeal. Don’t be afraid to ask lots of questions. The more information you have, the stronger your case.

The Five-Step Appeal Process

The five steps of a Medicare insurance appeal are very similar for both Original Medicare and Medicare Advantage plans. The largest difference is the first two steps, and who is reviewing the appeal.

In an Original Medicare plan, your first step is reviewing your MSN and submitting a redetermination request form. Once you submit this form, a Qualified Independent Contractor will review the request.

In a Medicare Advantage plan, if you disagree with the organization determination, you may request a reconsideration. This request must be made within 60 days of your organization determination. Your plan may decide against your reconsideration. If they do, your plan will be required to send you a notice that outlines the reasons behind their decision.

Your next option is to contact an Independent Review Entity (IRE) and inform them of your case. You must get this information to them within 10 days of receiving the notice from your plan. Once you are past step 2, the process for Original Medicare and Medicare Advantage appeals becomes the same.

Original Medicare

Level 1. Company handling Medicare program claims redetermination
Level 2. Qualified Independent Contractor (QIC) Reconsideration

Medicare Advantage

Level 1. Reconsideration from your plan
Level 2. Review by an Independent Review Entity

Both

Level 3. Decision by the Office of Medicare Hearings and Appeals
Level 4. Review by Medicare Appeals Council
Level 5. Federal district court judicial review

If you disagree with the decision made at any of the steps, you can move the process on to the next step. Once an appeal moves to the next step, you’ll receive a decision letter with instructions what to do and timeframes in which they need to be done.

In cases where you believe waiting for coverage is detrimental to your health, you can ask for a fast decision to be made. If the plan or doctor agrees, you’ll have your answer within 72 hours after filing the appeal. Otherwise, the standard decision time is 14 days.

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If you need help filing an appeal, you can appoint a representative to help you using the instructions found on Medicare.gov.

You and your doctor know your health best. If you ever feel that the Medicare program or your plan has wrongfully denied you coverage, an appeal is a powerful tool to ensure your voice is heard.

Further Reading

Medicare.gov — 5 things to know when filing an appeal
Medicare.gov — Appeals if you have a Medicare health plan