When you have to appeal a Medicare decision, it means that you are seeking to challenge a denial of coverage, a reduction in benefits, or a determination of a medical necessity. Appeals can be necessary if you believe that Medicare made an error in their decision, or if you disagree with the reasons given for denying coverage. The appeals process allows you to present additional information, medical records, or documentation to support your case and potentially have the original decision overturned. This process can be complex and time-consuming, but it’s important to pursue your appeal if you believe that you are entitled to the benefits or coverage that has been denied.
Here, we’ll provide a breakdown of how to appeal a Medicare decision.
The Steps Involved in Appealing a Medicare Decision
As mentioned above, appealing a Medicare decision can be a complex process, so remember to stay organized, persistent, and informed throughout the process to maximize your chances of a successful appeal.
- Understand the Type of Medicare Appeal You’re Filing
There are different appeal processes depending on the Medicare plan you have:
- Original Medicare (Part A & Part B): Covers hospital and outpatient care.
- Medicare Advantage (Part C): Managed care plans provided by private insurers.
- Medicare Prescription Drug Plans (Part D): Covers medications.
Each type follows similar steps but may have variations in deadlines or specific forms required. Ensure you’re following the correct path based on your plan.
- Review Your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB)
The Medicare Summary Notice (for Original Medicare) or the Explanation of Benefits (for Medicare Advantage or Part D) will tell you what service or item was denied, the reason for denial, and the instructions on how to appeal. These documents provide a starting point for your appeal by helping you understand what went wrong and whether an error may have occurred.
- Gather the Supporting Information
Before submitting your appeal, make sure you have the following information/supporting documents:
- Medical records or physician letters explaining why the service is medically necessary.
- Invoices or billing records to show that you meet eligibility or payment criteria.
- Any other relevant documentation that supports your claim.
You have a much higher chance of success if your documents are as detailed as possible.
- File Your Appeal – Level 1
For Original Medicare:
- Use Form CMS-20027 or follow the instructions on your MSN.
- File within 120 days of receiving your notice.
- Send the appeal to the Medicare contractor listed on your MSN.
For Medicare Advantage or Part D plans:
- Submit a “reconsideration request” to your plan provider.
- File within 60 days of receiving the denial.
- Reconsideration by a Qualified Independent Contractor (QIC) – Level 2
If your first appeal is denied, you can escalate to the second level. You must submit a request within 180 days of the first-level denial. The QIC is an independent entity that will review the decision.
- Hearing with an Administrative Law Judge (ALJ) – Level 3
If the QIC upholds the denial, you can request a hearing with an ALJ. The amount in controversy must meet a certain threshold (which changes yearly). You must request this hearing within 60 days of the QIC’s decision.
- Medicare Appeals Council (MAC) Review – Level 4
If the ALJ rules against you, you can take your appeal to the Medicare Appeals Council. This is an optional review step, but it can be helpful if you believe there were legal errors in the previous decisions.
- Federal Court Review – Level 5
As a final step, you can take your appeal to federal court if the MAC denies your appeal and the amount in dispute meets the required threshold. At this stage, it’s recommended to consult with an attorney.
- Monitor Your Deadlines!
Each step of the appeal process has specific deadlines. Keep track of these dates carefully to avoid missing opportunities to appeal.
- Work With a Professional
The appeal process can be complicated, especially if your case involves multiple levels. While you can seek assistance from your healthcare provider with gathering the necessary medical documents, you need to work with someone who can guide you with ease through every step of the process such as a Medicare agent. A Medicare agent is someone who can help you make the best healthcare decisions for your needs, but also guide you through the complex world of Medicare, no matter your goals.
Remember: You Always Have the Right to Appeal
Appealing a Medicare decision can feel overwhelming, but with careful preparation and persistence, you may successfully reverse a denial. Ensure you follow the specific steps for your type of plan, gather thorough documentation, and keep track of your deadlines to improve your chances of success. You can also always reach out to a professional for help. They know how to navigate the complexities of the Medicare world no matter if you’re looking for the best plan for you, or if you need to file an appeal.
Emily Trevino, Senior Managing Partner at Wise Insurance, leverages her extensive background in biology and business finance to master Medicare, health insurance, and retirement planning. With over a decade in the field, Emily has co-authored “Medicare Breakdown – The Alphabet Soup of Medicare,” marking her as a pivotal figure in insurance education. Her commitment extends through active participation in the National Association of Benefits and Insurance Professionals (NABIP) and speaking at major industry events. Emily’s drive for community service and personal resilience shines through her adventurous pursuits and dedication to societal well-being. Connect with Emily on LinkedIn to explore the future of informed insurance decisions.
