Medicare reimbursements can be tricky at times. Sometimes it can be challenging to understand where you stand with your Medicare claim. But don’t give up hope if Medicare denies your coverage!
All medical providers have the right to appeal any claim they believe has been incorrectly denied. And so, you can also submit an appeal if you feel your case falls into this category. The appeal process depends on the type of Medicare plan you own and how it handles appeals.
The process can be very complicated and emotionally exhaustive, especially for the loved ones being notified about denied coverage on their health care costs. In addition, it leaves many people questioning how coverage can be denied in a country that usually prides itself in being so generous with its citizens.
People often face an uphill battle when appealing their Medicare denials. They must remain vigilant against the obstacles posed by the Medicare appeals process. The challenges include dealing with complex forms and paperwork, managing their time to meet deadlines, communicating with medical providers and government entities, etc.
All of these factors can make the Medicare appeals overwhelming. Therefore, anyone reaching out to Social Security must speak with a qualified attorney before moving forward, as this complex system can easily cost people the benefits that they are entitled to.
Here are different processes to raise an appeal for different Medicare Plans.
How to File an Appeal in Original Medicare [Part A (Hospital Insurance) & Part B (Medical Insurance)]
Filing an appeal is a reasonable step for Medicare beneficiaries who believe that their coverage denial is invalid. However, if you are unfamiliar with Medicare coverage and its terms, the process can be confusing.
The appeal process in Original Medicare is no different than appealing for any other kind of billing error. It simply means that if your Medicare claims were denied, you have the right to appeal the decision and get a fair review of your claims.
Here’s how to file an appeal under Original Medicare;
- First, look at your “Medicare Summary Notice” MSN and check the appeal filing date. If you have missed the deadline, you must have a solid reason to file an appeal after it.
- Fill out the “Redetermination Request Form” and send it to the company that manages the Medicare claims – check their address in the “Appeals Information” section of the MSN.
Generally, you’ll get the decision within 60 days from the day the Medicare Administrative Contractor receives your request.
Filing an appeal under Medicare Part B is bound by a time frame. The rule of thumb for filing an appeal is 60 days from the date of receiving a notice from Medicare. In other words, once you get the notice from Medicare, you have to raise your appeal for the denied claim within 60 days. If you miss the duration and raise an appeal after 60 days, you have to provide a valid reason behind filing late.
Also, remember that the time frame is considered part of the law or regulation under which you file your appeal or request a fair hearing. For Part B, there is no preassigned review process outlined in the Medicare statute. Therefore, it leaves a lot of decisions up to the Secretary’s discretion.
How to File an Appeal in Medicare Advantage
The process for filing an appeal under Part C (Medicare Advantage) is very similar to that of filing an appeal under Parts A & B or Original Medicare. Notably, Medicare Advantage Plans involve rules set by Medicare and by the private insurance company. Therefore, you must consider the rules of both parties when filing an appeal.
To file an appeal in Medicare Part C, you must reach out to your insurer, which will generally provide you instructions to file an appeal. For any reason, if your insurer denies your appeal, you can request a review by an independent group affiliated with Medicare.
You can also ask for a “fast decision” if a coverage denial is costing your health. The insurer will get back to you within 72 hours.
How to File an Appeal Under Medicare Part D (Prescription Drug Plan)
Filing for a Medicare Part D may seem a little daunting at first, but if you take the time and make the necessary steps to complete all aspects of the request, there is nothing to get overwhelmed at.
The procedure to file for an appeal under Medicare Part D is quite similar to filing under Medicare Part C.
Consider the following steps once you find out that your plan won’t pay for a particular drug you need.
- Ask your doctor to suggest a different drug that is covered under your plan. If the physician insists on the same drug, then get an explanation and submit the request to the Medicare drug plan.
- If your request gets denied, file a formal appeal via phone or email with the help of your designated representative. You can choose “fast decision,” similar to Medicare Part C appeal, to get a response within 72 hours.
If your appeal still gets rejected, you can reach out to an independent organization affiliated with Medicare.
Your best chance for a successful appeal rests on specific kinds of information, so be sure to include this information in any correspondence with the claims examiner.
It is important to remember that when you appeal a denied Medicare claim, you are appealing to Medicare, not the provider. Therefore, your appeal package must be formatted appropriately, compelling, and persuasive for it to be successful. Failure to meet these requirements can fail your appeal at any level of the review process.
If you need any assistance in filing a Medicare appeal under any plan, you can reach out to Simpler Horizons Insurance Solutions. Our licensed agents specializing in Medicare will ensure that you can file a successful appeal with the minimum effort required.
Contact us now!