What You Need to Know About Medicare Appeals

What You Need to Know About Medicare Appeals

If you’re enrolled in Medicare and finding that your coverage does not fall in line with your needs or the payments you are making are becoming too costly, you can file an appeal. If you choose to file an appeal, you can contact your doctor, other healthcare providers, or your medical equipment supplier and ask if they would be willing to support your appeal by giving a statement.

How does an appeal work?

You can ask for an appeal if Medicare denies you one of these requests:

  • Your request for healthcare services, items, or drugs to be covered, provided or continued
  • Request for payment for a service you already received, such as a healthcare service or drug
  • Request for the amount to be changed for your healthcare service(s), items, or drugs

You also have the option to appeal if you think Medicare should continue providing or paying for healthcare services, prescriptions, medical supplies, or items that are no longer covered.

You can either file an appeal yourself or appoint a representative to help you through the process. Your representative can be anyone who will act on your behalf, such as a family member, friend, doctor, or attorney. However, your doctor can ask for a request on your behalf without needing to be an appointed representative.

Original Medicare Appeal

If you receive Medicare Part A and Part B coverage, you should be receiving a Medicare Summary Notice (MSN) every three months. The MSN shows everything that has been billed to Medicare within those three months, as well as what you owe. If you find that the MSN information is not up to your standards and disagree with the coverage or payment decisions, you can appeal. Your appeal rights will be listed in the MSN. Make sure to keep documented proof from your doctor or anything else that would benefit your case.

The appeals process for Original Medicare has five levels that you can agree or disagree with. If you disagree with the decisions made for a specific level, you can move on to the next. You’ll receive instructions on how you can go through the process of moving to the next level. The levels are:

  1. Redetermination by the Medicare Administrative Contractor
  2. Reconsideration by a Qualified Independent Contractor
  3. Decision by the Office of Medicare Hearings and Appeals
  4. Review by the Medicare Appeals Council
  5. Judicial Review by a Federal District Court

Medicare Advantage or Health Plan Appeal

You or your representative can request an organization determination if you feel Medicare should be covering or providing you services. The organization determination is the decision that’s made by your plan when you want that specific coverage. If the plan denies coverage after you have received those services, that denial is the organization determination that you can appeal. The appeals process for Medicare Advantage and other Medicare health plans consists of five levels:

  1. Reconsideration from your plan
  2. Reconsidered determination by an Independent Review Entity
  3. Decision by the Office of Medicare Hearings and Appeals
  4. Review by the Medicare Appeals Council
  5. Judicial Review by a Federal District Court

If you disagree with the decisions made for a specific level, you can move on to the next.

Medicare Prescription Drug Coverage

You will receive information about your rights with your plan called Evidence of Coverage. If you disagree with the coverage provided and need other prescriptions to be covered, you can request an appeal. The process for a Medicare Prescription Drug plan appeal consists of five levels:

  1. Redetermination from your plan
  2. Reconsidered determination by an Independent Review Entity
  3. Decision by the Office of Medicare Hearings and Appeals
  4. Review by the Medicare Appeals Council
  5. Judicial Review by a Federal District Court

If you disagree with the decisions made for a specific level, you can move on to the next.

At Reichardt Insurance, we are deeply rooted in our community. That’s why we are here to answer any questions you have regarding your Medicare plans. Give us a call today at (870) 698-2928 and schedule an appointment.

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