What Is The Medicare Appeals Process?

Share on email
Share on facebook
Share on twitter
Share on linkedin
Share on pinterest
Share on reddit

What Is The Medicare Appeals Process?

Share on email
Share on facebook
Share on twitter
Share on linkedin
Share on pinterest
Share on reddit
Share on email
Share on facebook
Share on twitter
Share on linkedin
Share on pinterest
Share on reddit

Question: My Medicare claim has been denied. I need to appeal my claim. What is the medicare appeals process and how does it work?

In this article we’ll discuss:

medicare appeals process

Not every Medicare claim that is filed will process smoothly the first time around. However, it’s pretty common and obvious to the medical billing staff what went wrong. When this happens, fixing the problem and re-opening or resubmitting your claim can end up fixing the problem without the appeals process.

Unfortunately, there are times when a submitted claim will be reviewed by the payer and results in a formal denial. Denied claims after a review by a Medicare contractor may happen for a variety of reasons. Let’s look into how the Medicare appeals process works.

When can I appeal a claim?

You will be able to appeal a claim if Medicare or your health plan denies one of these 3:

  1. Your request to receive a health care item, service, or drug you believe should be provided, continued or covered.
  2. Your request for payment for a health care drug, item or service that you have previously received.
  3. Your request to adjust the price you pay for a health care drug, item or service.

How do I file my appeal?

There are multiple appeals processes. The appeals process is determined by where you are filing. It will be a different process depending on which of the following 3 situations you’re experiencing:

  1. Original Medicare,
  2. Medicare Health Plan,
  3. Medicare Prescription Drug Plan

Which appeals process do you need help with? Click below on the process you need assistance with.

Original Medicare Appeal

Original Medicare

Learn how to appeal with Original Medicare
Click Here

Medicare health plan appeals

Medicare health plan appeals

Learn how to appeal with a Medicare Health Plan
Click Here

Prescription Drug Plan Appeals

Medicare PDP Appeals

Appeals with a Medicare Prescription Drug Plan
Click Here

Appeals with Original Medicare

If you only have Original Medicare, then the first thing you need to do is find your “Medicare Summary Notice” (MSN). You need to file your appeal within 120 days of the date you received your Medicare Summary Notice.

medicare appeals process flow chart

Below is a Medicare Appeals Process diagram. It walks you through each level of the appeals process and provides the timelines of determination.

medicare appeals process

Appeals with a Medicare health plan

When you have a Medicare health plan, like Medigap, then you should start the appeal process through your Medicare health plan.

Depending on the type of request, your plan may respond anywhere from 72 hours to 60 days. Here is a summary of the type of requests:  

  • Expedited (fast) request—72 hours
  • Standard service request—30 calendar days
  • Payment request—60 calendar days

Follow these steps for Health Plan Appeals:

If you are concerned about your health and feel it may become seriously harmed if you wait the standard 14 days for a decision, make sure to request that your plan asks for an “expedited” decision. Your health plan has to give you their decision within 72 hours if they determine (or your physician informs your plan) that waiting for the “standard” decision will potentially  jeopardize your health, life, or abilities to recover maximum function.

Appeals with a Prescription Drug plan

If you have Medicare drug plan coverage, you will need to begin the appeal process through your PDP plan.

Follow these steps for Prescription Drug Plan Appeals:

  • Are you requesting to get reimbursed for medications you already purchased? If you answered “Yes”, then you or your prescriber will have to complete the standard request in writing.
    • You can write your Prescription Drug Plan a letter, or complete the “Model Coverage Determination Request” form and send it to them. You can find the form here at the bottom of the page in the “Downloads” box.
  • Are you requesting prescription drug benefits that you haven’t received yet? If you answered “Yes”, then you or your prescriber may ask your drug plan for an exception or a coverage determination. Requesting a coverage determination or exception, you can complete one of the following:
    1. Complete and send in the “Model Coverage Determination Request” form.
    2. Write a letter to your drug plan
    3. Call your drug plan directly
    4. When requesting an exception, your prescriber has to provide a statement that explains why your exception should be approved by detailing your medical situation.
  • Are you someone who hasn’t received your prescription yet? If you answered “Yes”, then you or your prescriber may ask for the expedited request. This is the fastest request available. It will be expedited if your drug plan determines (or your prescriber informs your drug plan) that the standard decision time may cause significant health, life, or ability to regain maximum function.

Depending on the type of request, your plan may respond anywhere from 24 hours to 14 days. Here is a summary of the type of requests and their duration:  

  • Expedited (fast) request—24 hours 
  • Standard service request—72 hours 
  • Payment request—14 calendar days

Medicare Appeals Process FAQ

There are five levels with the Medicare appeals process.

Redetermination is the first level of the appeal process. You are able to access the CMS-20027 directly from CMS here. Fill out the form and send it to the company that handles claims for Medicare.

Overwhelmed by Medicare?

We know that Medicare can be confusing.  We also know that everyone’s situation is different. That’s why we’re here to help. Schedule your free 30-60 minute consultation now!

Joe Moynihan
Joe Moynihan
Facebook review
Read More
Best decision I made going through REMEDIGAP. I must have watched 40-50 videos from several different carriers and they mostly seemed shady. One I spoke to Joann and walked through options, received some quotes she took care of the rest with absolutely no pressure.
Billy Shows
Billy Shows
Facebook review
Read More
I wish I had found REMEDIGAP in the beginning. It would have saved me 3 months of headache. Joann is really awesome in the way she explains everything and she is a very genuine person.
Diane Langille-stone
Diane Langille-stone
Facebook review
Read More
This was the best thing I could have done for my self every thing was explained to me so I could make the best choice for me. And when I need help later they will be there for me.
Tammy Feola
Tammy Feola
Google review
Read More
Joann is top notch when it comes in explaining whatever question you might have in regards to supplemental insurance. She is professional, courteous, a lovely person to talk to. I feel at easy when talking to her. She is a great asset to your company.
READ ALL OUR REVIEWS!
READ ALL OUR REVIEWS!
Click above to read all our reviews from our wonderful clients!

Compare Medigap Plans

Join our 7-Day Medicare eCourse

Medicare doesn’t have to be so confusing. We’ll send you 7 email lessons with videos that will guide you through the Medicare process. We want you to be informed, confident and comfortable with your Medicare planning.