Can I Appeal a Medicare Denial? How?

If you disagree with a coverage of payment decision made by Medicare, you can appeal it.

You can appeal if Medicare has denied payment, will deny payment, has stopped providing payment, or didn’t pay what you thought they would for:

• a health care service,
• supply,
• item, or
• prescription drug.

Before you make any moves, talk with your agent. He or she will be able to guide you through the process, and they’ll also have insight as to what has been approved or denied in the past.

In general, you want to ask your healthcare provider or supplier for any information or documentation that could help your case.

Once you’ve done that, you’ll begin the appeal process. The Medicare appeal process has 5 steps. If you disagree with the decision at any step, you move to the next one.

Get the Medicare Appeals Cheat Sheet

Appeals Level 1: Fill out a Redetermination Request Form

Once you’ve pinpointed the service or supply item you disagree with, fill out a Redetermination Request Form.

Make sure you have your Medicare Summary Notice (MSN) handy – this is a list of all services or supplies you’ve billed to Medicare in the last 3 months. This is mailed to you every 3 months.

You must send in the Redetermination Request Form within 120 days of the date you received the MSN. (Note: If you’ve misplaced the MSN, you can find an electronic version by visiting MyMedicare.gov.)

The MSN will contain information about your appeal rights, including the address in which to send the appeal. Sometimes, the MSN will give other instructions about how to file an appeal, such as circling the things you disagree with and explaining in writing why you disagree with it.

In any case, make sure the form or letter you send includes the following information:

• Your name
• Your address and telephone number
• Your Medicare number
• The item or service you wish to appeal
• The date the service or item was received
• The date you received your MSN
• Why you disagree with the payment decision
• Signature and date of signature

If you were able to get any other supporting documents, make sure to write your Medicare number on them. Also, keep a copy of everything you send in during the appeals process.

In 60 days, you will get a decision from the Medicare Administrative Contractor (MAC). If you disagree, you have 180 days to move to Appeals Level 2.

Appeals Level 2: Fill out a Medicare Reconsideration Request Form

If you disagree with the decision made by the Medicare Administrative Contractor, fill out a Medicare Reconsideration Request Form. Be sure to include why you disagree with the previous decision.

The form or letter you send should include the following information:

• Your name
• Your address and telephone number
• Your Medicare number
• The item or service you wish to appeal
• The date the service or item was received
• The date you received your Redetermination Notice
• Name of Medicare contractor who made that decision
• Why you disagree with the redetermination decision
• Signature and date of signature

The letter you receive at the end of Level 1 will include the address in which to send this reconsideration request.

Within 60 days, you should a written response from a Qualified Independent Contractor (QIC).

If you disagree with this decision, move to Level 3. Note that you have 60 days to make the next step.

Appeals Level 3: Fill Out a “Request for Administrative Law Judge Hearing or Review of Dismissal” Form

If you didn’t get the result you wanted in Level 1 and 2, it’s time to ask for a hearing before a judge. Be sure you’re confident that you have a valid case before moving to this step. Your agent can help you determine this if you aren’t sure.

The previous letter you received will explain how to go about this next step. The address in which to send your request will be on that letter as well.

To request a hearing, fill out the “Request for Administrative Law Judge Hearing or Review of Dismissal” form.

This form will ask for your contact information, your representatives contact information, why you disagree with the previous decisions, the evidence you’re submitting, and other similar information.

There is a minimum dollar amount in order to get a hearing, which is $160 as of 2017. If you disagree with the decision made here, you have 60 days to move to the next step.

Appeals Level 4: Fill Out a "Request for Review of an Administrative Law Judge (ALJ) Medicare Decision/Dismissal" Form

If you still disagree with the decision made, you can move to Level 4, which asks the Medicare Appeals Council to review the judge’s decision.

Fill out a "Request for Review of an Administrative Law Judge (ALJ) Medicare Decision/Dismissal" form and send it to the address listed in the judge’s hearing decision.

If you disagree with decision as well, you can move to Level 4. You have 60 days to do this.

Appeals Level 5: Get a Judicial Review in Federal District Court

This is the final option if you still haven’t received the decision you were hoping for. In order to get a judicial review, your case must meet the minimum dollar amount, which is $1,560 as of 2017.

There aren’t any forms for this process; instructions will be listed on the letter you received from Level 4.

If you ever need help filing an appeal, ask for a representative here at Medicare Allies. We’d be happy to walk you through it and make the process as painless as possible.

Get the Medicare Appeals Cheat Sheet