For many American seniors, Medicare is a blessing. But for some it can be a curse instead, with rulings that don’t always make sense to you or your doctor. Fortunately, you can appeal Medicare decisions several times if necessary.
According to the Medicare Rights Center, 80 percent of Medicare Part A (hospital care) appeals, and 92 percent of Part B (doctor fees and lab tests) appeals are accepted in favor of the person appealing a decision. It’s a simple process for appealing decisions made about Medicare Parts A and B (also called Original Medicare) and Part D (for prescription plans).
The Parts Explained
Medicare Part A – Inpatient medical care. Covers hospital and skilled nursing facilities as well as some home health and hospice services.
Medicare Part B – Outpatient medical care. Includes doctor appointments, some home care, some lab tests, some medical equipment and some medications.
Medicare Part D – Prescription drug plan.
Medicare Advantage – You deal with both Medicare as well as your private insurance, which runs your Medical Advantage program.
Tips for a Successful Appeal
The Medicare Rights Center provides these tips for filing a Medicare appeal:
- Make copies of all communications.
- Write “PLEASE REVIEW” at the bottom of the medical summary notification (MSN) and return the completed form to the address provided on the form by certified mail or delivery confirmation.
- Write and include a letter explaining why the claim should be covered.
- If possible, include a letter of support from your health care provider explaining why the service is medically necessary.
- If you need help filing an appeal, contact your State Health Assistance Program (SHIP).
Original Medicare Plan
An Original Medicare Plan covers Medicare Part A and Medicare Part B. You’ll receive a record of an approval or denial of a claim in a medical summary notice (MSN), a document mailed to members every three months.
Here’s how an appeal progresses:
- Review your MSN, indicate the items in question and note the reason for the denial.
- State in writing on the MSN or a separate piece of paper, the particular benefit or service you’re appealing along with the reason you believe it should be approved.
- Fill out a Redetermination Request Form, sign it and write your Medicare number and phone number on the form.
- Send a copy of the completed form to the Medicare contractor whose address is listed on the MSN.
- Include documentation that supports your appeal.
You can request a fast appeal. Ask your health care provider for a notice for filing request instructions.
Medicare Part D
Medicare Part D covers prescription drug plans. Your Part D insurer provides a helpful booklet. Common plan-holder questions and requests include:
- Is a particular drug covered, if you’d qualify for it and how much you will pay for it?
- Ask for a special exception for: reduced pricing if the less expensive options don’t work for you.
- Request an expedited appeal through your doctor if your health is at risk if you wait for a medication approval from your plan
Medicare Advantage Plans
Administered by private insurance companies, Medicare Advantage Plans provide an appeals process. Your insurance company can provide instructions.
- Find various forms needed on the CMS.gov (Centers for Medicare and Medicaid website.
- Deadlines, timelines and requirements depend on the Medicare part you are appealing.
- Need help with an appeal? Contact your State Health Insurance Assistant Program (SHIP).