You may consider making an appeal to Medicare if you are denied coverage for a health service, supply, or prescription medication you think you are allowed to receive or should be allowed to receive under your policy. Additionally, you may want to request payment for a health service, supply, or prescription medication that has already been received or dispute the payment amount covered by insurance for a health service, supply, or medication already received.
If you have “Original Medicare,” there are 5 stages to the appeal process beginning with a re-determination by the company that handles that type of Medicare claim, and ending at the final stage with a Judicial Review in a Federal District Court. In most circumstances if you disagree with a determination or decision made at any level of the appeal process you can escalate your case to the next highest level of appeal.
Please see the following link to learn more about appealing an Original Medicare policy decision:
Before you appeal:
- Collect supportive materials and get your paperwork including bills and documentation in order.
- Contact your healthcare practitioner, medical supplier, or pharmacy to let them know you are beginning an appeal and see if they have any collateral information which would support your case.
- Look at the details to understand why your claim is being denied.
Once you begin an appeal:
- Pay attention to stated timeframes and deadlines. If you do not return forms or requested materials and documents in a timely fashion it may jeopardize your appeal.
- Obtain assistance as needed. If you feel there are aspects of your appeal that you do not understand or language you are not familiar with, follow up with support organizations such as the Medicare Rights Center http://www.medicarerights.org/ to better understand what options and assistance you may have with your appeal.
Medicare Advantage Plans (Part C) and Medicare Prescription Drug Plans (Part D) maintain a different set of appeals processes.
To learn about Medicare Advantage Plan appeal processes: http://www.medicare.gov/claims-and-appeals/file-an-appeal/medicare-health-plan/medicare-health-plan-appeals.html
To learn about the Medicare Prescription Drug Coverage appeal processes including a “Model Coverage Determination Request form”: http://www.medicare.gov/claims-and-appeals/file-an-appeal/prescription-plan/prescription-drug-coverage-appeals.html