How and when to file a Medicare Appeal
When you are enrolled in Medicare you have certain rights. One of those rights is to file an appeal with Medicare. For our purposes it’s important to note that a filing Medicare appeal is different from filing a grievance or complaint with Medicare.
A filing a Medicare appeal is your recourse if you disagree with coverage or a payment decision made by Medicare or by your Medicare plan. A Medicare plan can be defined as either a Medicare Advantage plan or a Part D plan. Filing an appeal against an insurance company that provides your Medigap coverage is a moot point because that policy pays only if Medicare pays.
You can file a Medicare appeal if Medicare or your plan denies:
- A request for a health care service, prescription drug or medical supply that you think you should be able to get
- A request for payment for a service, prescription drug or supply item that you believe you should get
- A request for payment for a service, prescription drug or supply item that you have already received
- A request to change the amount you are required to pay for a healthcare service, prescription drug or supply item
A complaint or grievance can be filed if you are unhappy about the way a Medicare health plan or drug care is providing care.
Filing a Medicare appeal if you are enrolled in a Medicare Advantage plan versus original Medicare
If you are filing a medicare appeal and are enrolled in original Medicare you will need to follow the directions included at medicare.gov. These include getting your “Medicare Summary Notice” and circling the item you disagree with. You will need to include an explanation as to why you disagree and include your name, phone number and medicare number. You will then send that information to the company listed on the Medicare Summary Notice. you will need to keep a copy of your medicare appeal and file it within 120 days of the date you get the Medicare Summary Notice in the mail.
If you are enrolled in a Medicare Advantage plan you will find instructions related to filing a Medicare appeal through the company included with the enrollment documents. This is information that you should retain when you enroll in the plan.
A note about retaining documentation… It is imperative that you keep all of your enrollment kit other than the application. Additionally, any notices you receive from the plan should be READ and kept in safe place. All statements that you receive from the plan or providers should be read and kept as well.
Filing a Medicare appeal will be a lot more difficult if you do not have documentation to support your claims. Keep everything!
Getting help filing your Medicare appeal
If all this seems a little overwhelming there is good news. You can get help filing your appeal with Medicare or your Medicare plan. This may not be a bad idea as the process can be somewhat confusing, especially given the fact that there are five different levels of appeals.
If you would like help, contact your State Health Insurance Assistance Program (SHIP). The phone number is on the back cover of your Medicare & You Handbook. You did keep the handbook… right? If not, you can find your State’s SHIP contact information here.
Filing a Medicare appeal is your right and you should do so if you do not agree if you feel that you have been denied the services or care that you expect.
I had to appeal to a Medigap plan last month because the would not pay for part of a Part B claim that involved the psychiatric reduction. That claim was for service in 2013 and fortunately the psychiatric reduction has been completely phased out in 2014, but I had to argue with the Medigap insurer for over 8 years for coverage for this item back in the days when the reduction was 50%.
Franco, That’s great! It helps to know your rights and then take the appropriate action.