Medicare Appeals Process
You have the right to file a Medicare appeal in certain situations, including if you believe Medicare or your insurer refused to pay for or denied you access to a medical service or drug you need. The Office of Medicare Hearings and Appeals administers the Medicare appeals process.
When Can You Appeal a Medicare Claim Decision?
If you disagree with a decision on one of your Medicare claims, you can appeal that decision. There is a time limit that varies depending on whether you’re appealing a claim on Medicare Part A, Part B, a Medicare Advantage plan (Part C) or a Part D prescription drug plan.
- Medicare or your insurer denies your request to get a health care service, product or drug that you think should be provided, covered or continued.
- Medicare or your insurer denies your request for payment of a health care service, product or drug that you already received.
- Medicare or your insurer denies your request to change the amount you have to pay for a medical service, product or drug.
What to Know Before Filing an Appeal
The Medicare appeals process can be long and complicated. You should begin your case with as much information and documentation as possible before filing an appeal. You can also contact your State Health Insurance Assistance Program (SHIP) if you need help filing your appeal.
- The insurer that administers your plan must tell you in writing how to appeal.
- Ask your doctor or other health care provider for any information that may help your case.
- If you believe waiting for an appeal to be decided could seriously affect your health, you can ask Medicare or your insurer for a quick decision. If the plan or a doctor agrees, they have 72 hours to make a decision.
- If you think you’re being discharged from a hospital too soon, you have the right to an immediate review. The hospital will not be able to force you to leave and you won’t have to pay for the hospital stay while your appeal is reviewed.
- If Medicare or your insurer decides you no longer need skilled nursing center services and you disagree, you have the right to a fast-track appeal.
Appeals Process for Original Medicare
- Level 1: Redetermination
- The appeal is carried out by the Medicare Administrative Contractor (MAC). If you disagree with the MAC’s decision, you can request a second look or review by different people in the MAC. You have 120 days to appeal to the next level.
- Level 2: Reconsideration
- This is handled by a Qualified Independent Contractor (QIC), which is an independent contractor who was not involved in the first level of the appeal. If you disagree with this decision, you have 60 days to appeal to the next level.
- Level 3: Disposition
- This appeal requests a decision by the Office of Medicare Hearings and Appeals. Your appeal will be heard by an administrative law judge or in some cases reviewed by an attorney adjudicator. To get to this level, you will need to have a minimum cost of the service, product or drug originally denied. In 2020 it was $170. If you lose this appeal, you have 60 days to appeal to the next level.
- Level 4: Review
- You can request a review before the Medicare Appeals Council regardless of the dollar amount. If you disagree with the council’s decision, you have 60 days to request a judicial review of your appeal.
- Level 5: Judicial Review
- This would be before a judge in a federal district court. To qualify, the amount of your denied service, medical product or drug must total $1,670 in 2020.
Medicare Advantage Appeals
Rules for Medicare Advantage (Part C) appeals can vary based on your Part C insurance provider.
Medicare Advantage plans are administered by private insurance companies that contract with Medicare to provide all your Original Medicare coverage. Some may also include Part D prescription drug coverage.
Medicare requires all of these companies to have an appeals process in case you disagree with the plan denying coverage of your health care.
The initial appeals process can vary from company to company. But after the first two rounds, the last three levels are the same as those for Original Medicare appeals.
Appeals for Medicare Part D Prescription Drug Plans
Like Medicare Advantage, the Medicare Part D prescription drug plan appeal process starts with appealing to the private company that administers your drug coverage.
- Reimbursement for Drugs
- You or the doctor who wrote the prescription makes a request in writing or sends the insurer a completed Model Coverage Determination Request form. You can download it from the Medicare forms page.
- Asking for Drug Benefits
- You or your prescriber can request determination or exception. You can use the form above, write your own letter or call your plan’s administrator.
- Still Waiting on Drugs
- You or your prescriber can ask for an expedited decision on your appeal if you can show that waiting for it could seriously jeopardize your life, health or recovery.
Your plan must respond within a certain time for any request you make. Expedited requests have to be answered in 24 hours compared to 72 hours for a standard service request. But the plan has 14 days to respond to a request for payment.
7 Cited Research Articles
- U.S. Department of Health and Human Services. (2020, April 9). Office of Medicare Hearings and Appeals (OHMA). Retrieved from https://www.hhs.gov/about/agencies/omha/index.html
- U.S. Centers for Medicare & Medicaid Services. (2020, February 11). Grievances. Retrieved from https://www.cms.gov/Medicare/Appeals-and-Grievances/MMCAG/Grievances
- U.S. Centers for Medicare & Medicaid Services. (2020, January). Medicare Parts A & B Appeals Process. Retrieved from https://www.cms.gov/outreach-and-education/medicare-learning-network-mln/mlnproducts/downloads/medicareappealsprocess.pdf
- U.S. Centers for Medicare & Medicaid Services. (2019, October). Medicare Appeals. Retrieved from https://www.medicare.gov/Pubs/pdf/11525-Medicare-Appeals.pdf
- AARP. (2012). Appealing a Medicare Claim Decision. Retrieved from https://www.aarp.org/health/medicare-insurance/info-05-2011/appealing-a-medicare-claim.html
- U.S. Centers for Medicare & Medicaid Services. (n.d.). How Do I File an Appeal? Retrieved from https://www.medicare.gov/claims-appeals/how-do-i-file-an-appeal
- U.S. Centers for Medicare & Medicaid Services. (n.d.). 5 Things to Know When Filing an Appeal. Retrieved from https://www.medicare.gov/claims-appeals/file-an-appeal/5-things-to-know-when-filing-an-appeal