Not every service or expense is covered under Medicare Part A or Part B and sometimes the patient and Medicare administrators can disagree over whether an expense should be covered.
If Medicare denies your claim under Parts A or B (hospital coverage or doctor’s office coverage, respectively), you have the right to appeal. But you need to know the process.
The Medicare appeals process consists of five levels. The first three are pretty straight ahead, if you follow directions.
The highest three levels may require some attorney or professional advisor assistance, because of their complexity and the standards of proof required to prove your case.
Standard appeals
Level 1: Request for redetermination — For most Medicare denials, the process begins with a Level 1 Appeal — Request for Redetermination.
You must file a written request for redetermination within 120 days of receiving your Medicare Summary Notice. This document will contain detailed information on what documents you need to send and where to send them.
Level 2: Request for reconsideration — If your Level 1 appeal is denied, you can file a Request for Reconsideration by a Qualified Independent Contractor.
This starts the process for a different Medicare benefits administration firm to conduct an independent assessment of your claim. You must file your request within 180 days of receiving a decision on your Level 1 appeal.
Level 3: Administrative law judge hearing — If your Level 2 appeal is not satisfactory, the next step is to file for an administrative law judge hearing with the Office of Medicare Hearings & Appeals. The OMHA will only hear cases in which the combined amount of all claims in dispute is $160 or more.
Your Level 2 appeal documents will provide information on how to file a Level 3 appeal. You’ll be asked to explain why you disagree with the reconsideration decision being appealed.
Level 4: Review by Medicare Appeals Council — If your claim is denied by the administrative law judge, you may file an appeal with the Medicare Appeals Council.
You have 60 days from the time you receive notice of your unsuccessful Level 3 appeal to file a Level 4 appeal. You can also file this appeal if the OMHA does not provide a timely decision in your Level 3 appeal.
The Medicare Appeals Council is the final level of appeal if your unresolved claim is worth less than $1,560.
Level 5: Judicial review by federal district court — For amounts in dispute of $1,560 and greater, and the results of the Medical Appeals Council review are unsatisfactory, you can get a judicial review from a judge in a federal district court.
You have 60 days to file a request for such a review from when you receive the council’s decision notice.
Expedited appeals
If a health care facility is trying to discharge you and you believe you should not yet be discharged, there is an expedited appeals process for this purpose.
Your care facility should provide you with a document called “An Important Message From Medicare About Your Rights.”
This document will contain information on how to contact and file an appeal with the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) in your area. If you don’t receive this document, ask for it.
You must ask for an immediate review not later than midnight on the day of your scheduled discharge. As long as you meet this deadline, you will not be held liable for the full cost of your care until the review board makes its decision.
There is a second level of expedited appeal, which you must initiate before noon on the date of your scheduled discharge.
For more information about the Medicare appeals process, dial 1-800-MEDICARE, or visit the Medicare website, www.medicare.gov
