Appeals Process – Government-Funded Plans

Medicare, Children’s Health Insurance Program, Medicaid and TRICARE health programs have their own appeal process.

Medicare Appeal Process
You have the right to file an appeal with any Medicare program if one or more of these requests are denied:

  • A request for a health care service, supply, item or drug that your physician prescribes.
  • A request for payment of a health care service, supply, item or drug you already received.
  • A request for continued coverage of health care service, supply, item or drug that your physician considers medically necessary.
  • A request to change the amount you must pay for a health care service, supply, item or prescription drug.

You can also appeal if Medicare or a Medicare-approved plan stops providing or paying for all or part of a health care service, supply, item or prescription drug you think you still need.

If you need help filing your appeal, contact your State Health Insurance Assistance Program (SHIP).

 

Appeal Process Overview

Original Medicare

If you have Original Medicare, you’ll get a Medicare Summary Notice (MSN) in the mail every three months if you have received any services.

Like an Explanation of Benefits (EOB), the MSN shows all items and services that providers billed to Medicare during the 3-month period, what Medicare paid, and what you may owe. The MSN also shows you if Medicare has fully or partially denied your medical claim. This is the first determination, and it’s made by the company that handles claims for Medicare. Read the MSN carefully. If you disagree with a Medicare coverage or payment decision, you can appeal the decision. The MSN contains information about your appeal rights and how to appeal. 

What your plan covers is based on Medicare’s National Coverage Determination (NCD) or Local Coverage Determination (LCD) of the services. If the denied service is not included on either list, you will not be able to appeal. If it is, then a billing or coding error may be the reason why the claim was denied.

Here is an example scenario:

When you turn 50, your first colonoscopy is considered a preventive care benefit, as mandated by the Affordable Care Act. You should not be charged, even if you have a deductible. Charges for this service will include invoices from the gastroenterologist (who performs the procedure), the medical facility (where the procedure is done) and the anesthesiologist (who administers anesthesia during the procedure). If a polyp (growth of cells) is found during the procedure and the doctor or facility includes a medical diagnosis code on the bill instead of a preventive service code, a cost to you may be triggered when Medicare processes the bill. In this case, you’ll need to follow up with the health care provider so that the bill can be resubmitted with the proper code. 

If your claim is denied for other reasons, Original Medicare appeals process has 5 levels.

Level 1: Redetermination by the Medicare Administrative Contractor (MAC)
Level 2: Reconsideration by a Qualified Independent Contractor (QIC)
Level 3: Hearing before an Administrative Law Judge (ALJ)
Level 4: Review by the Medicare Appeals Council (Appeals Council)
Level 5: Judicial review by a federal district court

At each level, you'll be given instructions in the decision letter on what to do and how to move to the next level of appeal. 

Getting Started

Before you begin the appeal process, here are some steps to get you organized.
  1. Create a communication log or use our template
  2. Use it to keep track all communication - dates and types of correspondence (letters, phone calls, emails, faxes), names of people you speak with, summaries of your conversations, dates of packages sent and received
  3. Keep a paper and electronic file of original documents (e.g. letters, forms, medical records, insurance documents, medical journal articles)
Ask your doctor or other health care providers for information that may help your appeal, including:
  1. A letter from your treating provider stating the medical reasons the service, procedure or medication should be approved. We have provided an example of an appeal letter from your physician.
  2. Relevant medical records or treatment history from your physician.
  3. Results of any relevant tests or procedures related to the requested service or procedure.
  4. Peer-reviewed articles or studies documenting the medical effectiveness of the requested services or treatments being recommended.
Any appeals will be reviewed by a Medicare Intermediary (a Medicare contractor assigned in your state). 

This brochure provides additional details for Medicare Part A and Part B appeals.

If you’re in a PACE (Program of All-inclusive Care for the Elderly) program, your appeal rights are different. The PACE organization will provide you with written information about your appeal rights.

Medicare Plans Administered by Private Insurers

When you join a Medicare Advantage, Cost, Drug Coverage or Supplemental plan, you’re still in the Medicare program. The appeals process for these plans has five levels:

Level 1: Reconsideration from your plan (the private insurer that administers the plan dictates this level and it will likely be similar to the internal review process used for their commercial plans)
Level 2: Review by an Independent Review Entity (IRE)
Level 3: Hearing before an Administrative Law Judge (ALJ)
Level 4: Review by the Medicare Appeals Council (Appeals Council)
Level 5: Judicial review by a federal district court 

Getting Started

Before you begin the appeal process, here are some steps to get you organized
  • Create a communication log or use our template
  • Use it to keep track all communication - dates and types of correspondence (letters, phone calls, emails, faxes), names of people you speak with, summaries of your conversations, dates of packages sent and received
  • Keep a paper and electronic file of original documents (e.g. letters, forms, medical records, insurance documents, medical journal articles)
Ask your doctor or other health care providers for information that may help your appeal, including:
  • A letter from your treating provider stating the medical reasons the service, procedure or medication should be approved. We have provided an example of an appeal letter from your physician.
  • Relevant medical records or treatment history from your physician.
  • Results of any relevant tests or procedures related to the requested service or procedure.
  • Peer-reviewed articles or studies documenting the medical effectiveness of the requested services or treatments being recommended.
At each level, you'll be given instructions in the decision letter on how to move to the next level of appeal. Keep a copy of everything you send to and receive from Medicare or the insurer who administers the plan as part of your appeal.

Centers for Medicare and Medicaid Services offers a brochure about the appeals process for Medicare Advantage and Medicare Drug Coverage. CMS’ website also has several resources available to help guide you step-by-step through the process.
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