Medicare Appeals

We’ve all received one of “those” letters. You know, the one that says your Medicare claim is being denied for (fill in the blank) reason. You have the right to appeal any decision made by Medicare. An appeal is a formal request for review of a decision made by your Original Medicare, Medicare Advantage, or Part D plan. 

Be sure to read all letters and notices from Medicare or your insurer. If the reason for denial is not clear, call 1-800-MEDICARE or your Medicare Advantage or Part D insurer. Once you are clear as to why your claim was denied you can begin the appeal process.

Appeal Letter 

Your Appeal Letter should address the specific reasons your claim was denied and why you are appealing the decision. Take careful note of the time frame for appeals. Be sure to include any supporting evidence for your claim. A letter from your doctor helps substantiate your appeal. Don’t forget to keep copies of all paperwork. Copies of postmarks can be helpful.

What do I do if they still deny my claim?

Don’t give up! There is more than one level of appeal and you have the right to continue the appeal process. Please note that each level of appeal has its own separate time frame. Pay special attention to these. If your appeal is submitted past the deadline it may not be considered. You may file a “good cause extension” in the event you cannot meet the deadlines due to extenuating circumstances. 

There is often a lengthy and time-consuming exchange of information and communication between your physician and Medicare, your Medicare Advantage, or Part D insurer. Be patient, know your rights. 

Available Links (from Medicare Rights Watch)

The links below describe the various parts of the appeal process.

1. Original Medicare appeals – This section includes information about how to appeal a denial of coverage by Original Medicare.

2. Medicare Advantage appeals – This section includes information about how to appeal a denial of coverage by your Medicare Advantage Plan. Keep in mind that the process differs depending on whether you are filing a pre-service appeal (you have not yet received your service) or post-service appeal (you have already received your service).

3. Part D appeals – This section includes information about how to appeal a denial of coverage by your prescription drug plan. You follow the same process regardless of whether you have a stand-alone Part D plan or a Medicare Advantage Plan that includes your prescription drug coverage.

4. Premium appeals – This section includes information about how to appeal an Income-Related Monthly Adjustment Amount (IRMAA) determination (meaning you pay a higher Part B or Part D premium).

No one likes to be denied coverage and it takes time to follow the appeal process. It can be frustrating at times but you might be surprised by the outcome and save a little money…