Medicare Appeals and How to File One

Have you ever had your Medicare claim denied and wondered what options you have? Well, filing an appeal is one place to start. If you aren’t sure what an appeal is, it’s an action that you can take if you disagree with Medicare’s decision on your coverage or payment.

For example, Medicare could deny a medical service you had, and you would receive a bill. If you think Medicare should have covered that service, you can appeal the denied claim, but we’ll get into that later.

Filing an appeal can help you provide more information about the situation and see if the decision can get overturned. However, it’s essential to know how to file an appeal. If you don’t have a plan through Boomer Benefits, you might need to do it yourself if your claim gets denied.

Medicare appeals

You may request an appeal for several reasons, such as if Medicare denies a service you think should have been covered, denies a request for payment for a service or denies a request to change the amount of a service. Additionally, if Medicare stops covering a service, drug, or item you think should still be covered, you can appeal that decision.

Knowing your options and what you can do if your service is denied is important. You don’t want to ignore the denied claim because it could go to collections if you don’t pay for the service. Therefore, if you believe your service should have been covered by Medicare, filing an appeal is an action you can take.

Process of filing an appeal

Medicare will send you a Medicare Summary Notice (MSN) that shows your services within the three-month period, what Medicare paid for those services, and the amount you may owe. You can proceed with your appeal if there are discrepancies with the services or payments listed on the MSN. You must submit the request by the date stated on your MSN.

To start the appeal process, you can complete a Redetermination Request Form which is your first level of appeal. Once that is complete, you can submit it to the company that handles Medicare claims.

A Medicare Administrative Contractor should send you a decision within about 60 days after they receive your request. If approved, that service will show on your next MSN.

What happens if it’s denied again?

If the decision from level 1 is denied, you will have 180 days after that notice to request a Qualified Independent Contractor (QIC) to reconsider it. This part of the process is known as appeal level 2. The QIC was not part of the first appeal; therefore, they will review your request and decide. The form you will need to complete is the Medicare Reconsideration Request Form.

This is your time also to explain why you disagree with the first appeal decision while providing any additional information that can prove why it should be approved. Similar to the first appeal, you should receive a notice within about 60 days after they receive the appeal request.

If it gets denied again, you can go onto the third appeal level, which goes to the Office of Medicare Hearings and Appeals (OMHA). If your request is denied for the third time, you can send your request to level 4, which the Medicare Appeals Council reviews. The last level of appeal is level 5, which the federal district court reviews.

Final points

The appeal process might seem tedious or overwhelming, but it can be worth it if you feel your service or payment should have been approved. Denied claims happen with Medicare, so don’t panic if you experience one. You can follow the steps in your MSN and submit an appeal!

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