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).
The state Medicaid agency must notify all beneficiaries of their appeal rights. The notification will include information on how to request a hearing and other procedures to follow. The communication must be received at least 10 days before Medicaid terminates, suspends or reduces of your eligibility or covered services. If you are currently receiving services you have the right to request that services continue during an appeal until a hearing decision is issued by requesting a hearing within the 10-day advance notice period.
In addition to the state’s responsibilities and processes, all managed care companies and private insurers that serve Medicaid beneficiaries must have an internal appeal procedure and a grievance process for enrollees to challenge denied coverage or payment of services.
You have only 60 days to appeal a Medicaid denial. You have up to 90 days to appeal if you have a good reason for being late (e.g., you were in the hospital). After your appeal is received, you will get a notice in the mail called "Request for State Hearing." If you don’t receive this notice within a week of asking for an appeal, contact your Medicaid office. All communication with Medicaid should include your social security number.
If your appeal is related to a service or equipment that has changed due to a new state-wide policy, your rights may be limited but you can request an exception or modification to the policy.
The steps of the appeal process will differ by state. In general, after your appeal is received, you may go through a mediation process. This is an informal process in which both parties are guided through a discussion by a neutral, third-party mediator to see if they can reach an agreement. If mediation does not resolve the issue, the next step is a hearing at the Office of Administrative Hearings (OAH) before an Administrative Law Judge. The hearing involves presenting evidence, including introducing documents, allowing someone to testify on your behalf, and making arguments to an Administrative Law Judge.
If you have military insurance and are denied medical services or equipment you can file an appeal. There are three types of denials that can be appealed:
- a request for preauthorization was denied
- a request for medical care was denied
- a request for an extended hospital stay after the proposed discharge date was denied
For denied preauthorization, you will need to file a "non-expedited preauthorization appeal." The letter of reconsideration must be submitted within 90 days of the denial. You should get a response notifying you of the decision, and any other appeal rights within 30 days of receipt of your letter.
For denied medical care or hospital admission, you need to file an "expedited review of a preadmission/pre-procedure denial." This appeal must be submitted three calendar days after the initial denial. You should receive a response no later than three days after your request has been received.
For a denial of an extended hospital stay, you will need to file a "concurrent review denial." This should be submitted no later than 12 noon on the day after you receive the initial denial. You should receive a response within three days after your letter is received.
If your appeal is denied, you can request a second-level review. The right to a second-level review is not guaranteed and may be based on what is being appealed. You will receive instructions on requesting a second review when you receive notification that your appeal has been denied. If your second level review is unsuccessful and the dispute is worth more than $300, you can request a hearing. You will receive instructions on this final process if applicable.
There are two TRICARE decisions that can’t be appealed:
- the amount TRICARE will pay for a service.
- a denial because you received services or care from a provider who is not authorized under the TRICARE program.
State-Children’s Health Insurance Plan Appeals Process
CHIP is jointly funded by state and federal governments just like Medicaid, and each state has a different interpretation of the program.
Each state has its own appeal process. Regardless of where you live, here are some important steps to follow:
- Read and follow the health plan instructions carefully before seeking care.
- Get in the habit of keeping documentation of medical records, lab tests, referrals, services and charges.
- Enlist your child’s doctor as your advocate (to provide letters of medical necessity and other supporting information).
- Stay abreast of articles in peer-reviewed journals that can be used to make your case on appeal.