How do I appeal the denial of a Medicare claim?

By: LawInfo

Published: 03/2009

If you file a claim with Medicare for a product or service related to your health care that you think Medicare should pay for, and Medicare denies your claim, or doesn’t pay the entire claim, you can file an appeal. You can file an appeal whether you receive benefits through the original Medicare Plan, a Medicare managed care plan, or the Medicare prescription drug plan. By following some simple steps to appeal the denial of your claim, you can ask Medicare to reconsider its decision about your coverage for a product or service.

Different companies administer the billing for original Medicare Plan claims. Therefore, you should first take a look at the notice that you receive from the billing company that denies your claim for benefits. On the back of that notice, which is often called an Explanation of Medicare Benefits, there are instructions about appealing your claim.

If you receive benefits under a Medicare managed care plan, you should have received a document that you that gives you information about how to file an appeal of the denial of a claim. If you think that the denial of your claim will have a serious effect on your health, you can also ask for a fast decision, which gives the plan only 72 hours in which to reconsider your claim. If your doctor supports your request for a fast appeal, you will automatically receive a fast appeal.

The notice that denies any kind of Medicare claim will give you a telephone number to call if you want to file a fast appeal, and an address to put your appeal in writing if you want to request a regular appeal. You generally have to file your appeal within 60 days after the date of the denial notice. You can appeal the claim yourself, or you can have a family member, friend, or attorney help you with your appeal.

As with the Medicare managed care plan, if you receive benefits under a Medicare prescription drug plan, the plan must give you written information about appealing a claim that it has denied to the plan sponsor, which is called asking for a coverage determination. When you ask for a coverage determination, the plan sponsor must answer you within 72 hours, or within 24 hours if you request a fast decision. If you still do not agree with the coverage determination, you can appeal that decision to the plan sponsor within 60 days of the denial. The plan sponsor has 7 days to process your appeal, or 72 hours for a fast appeal. If you still don’t agree with the appeals decision, you can then further appeal to an independent review organization, which must review your claim within 7 days, or 72 hours for a fast appeal.

If you exhaust these appeals processes, and you still aren’t satisfied with Medicare’s decision about your claim, you can further appeal the denial of your claim by asking for a hearing in front of an administrative law judge. There are further appeals options beyond the administrative hearing, as well, including review by the Medicare Appeals Council, and filing a lawsuit in federal district court. Since there are strict timelines and procedural requirements for these sorts of appeals, you should really contact an attorney to help you out if you get this far along in the appeals process.

You can get appeals forms for Medicare claims online, or you can contact the organization that denied your claim by using the contact information on your denial notice.