Question: My Medicare claim has been denied. I need to appeal my claim. What is the medicare appeals process and how does it work?
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:
- Your request to receive a health care item, service, or drug you believe should be provided, continued or covered.
- Your request for payment for a health care drug, item or service that you have previously received.
- 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:
- Original Medicare,
- Medicare Health Plan,
- Medicare Prescription Drug Plan
Which appeals process do you need help with? Click below on the process you need assistance with.
Original Medicare Appeal
Medicare health plan appeals
Prescription Drug Plan Appeals
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.
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:
- Make sure that you follow the directions in your plan's initial denial notice and plan materials.
- You, your doctor or representative must request an appeal from your health plan within 60 days from the documented date of coverage determination.
- Include these details with your written request: Your full name, address & Medicare Number on your Medicare card [JPG]
- List the services and/or items for your reconsideration request, the service dates & a detailed reason why you're appealing.
- If you've appointed a representative, you need to include their name & proof of representation.
- Provide any additional information that can help your case.
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:
- Complete and send in the “Model Coverage Determination Request” form.
- Write a letter to your drug plan
- Call your drug plan directly
- 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.
