How Do I File a Medicare Appeal?

There are a few instances when a Medicare beneficiary may not agree with Medicare’s coverage decisionsl. Luckily, beneficiaries have the right to appeal any decision they don’t agree with. Here is what you need to know about how to file a Medicare appeal and when you can file.

When you can File a Medicare Appeal

If Medicare denies a request for a service, medical equipment or device, or prescription drug that your doctor believes is medically necessary for your health condition.
If Medicare denies a service, device, or prescription drug that you’ve already received from your doctor. For example, if Medicare denies payment for a service your doctor performed during an office visit.
Denial of a request made by your doctor to reduce the amount you pay for a medication. If your doctor recommends you take a more expensive drug because the cheaper drug won’t be effective for your health condition and your Part D plan denies it, you can then file an appeal.

Filing an Appeal for Part A or B

If you receive a Medicare Summary Notice with a denial you want to appeal, you have to file the appeal within 120 days. Note on the document the specific item on your summary notice you want to appeal and include information to support your appeal. Your doctor may be able to provide additional helpful information to include to support your case.

Be sure to carefully review the instructions contained in the MSN document. Make copies of documents and receipts for safekeeping before sending your appeal to the address on your summary notice.

Filing an Appeal for Medicare Advantage (Part C)

Medicare Advantage plans are separate from Original Medicare (Parts A and B) because they are administered by private insurance carriers but still regulated by the traditional Medicare program. This means that Advantage plans have to provide a process for their beneficiaries to appeal claims.

If the plan makes a decision that goes against you on appeal, you can move up to the next level of appeals to the Medicare Appeals Council, an administrative law judge and federal court.

Additionally, beneficiaries of Medicare Advantage plans can report grievances about their plan and the quality of care they get from providers in the plan.

Filing an Appeal for Part D

Special exemptions are allowed under Part D coverage if your doctor thinks that a medication that isn’t covered under your plan is needed to treat or manage your medical condition. You can also request to pay a discounted price for a higher-priced drug if the cheaper option isn’t effective for you.

Your doctor can either call the plan to request an exception or submit a written request.

If you’ve already bought the medications, you must submit a request for reimbursement in writing. If your health or life is at risk because you have to wait for a prescription drug to be approved by your plan, your doctor can ask for an expedited appeal.
You are allowed to file a formal appeal if you don’t agree with the decision made by your Part D plan. Filing an appeal directly with your plan is the first level of appeal. Within seven days of filing a regular appeal, the plan is required to notify you of its decision. For an expedited appeal, they are required to notify you within 72 hours. Independent reviews of your case are allowed if you don’t agree with the exception decision.

When filing a Medicare appeal, ask your health care provider, doctor, or supplier for information that may help your case. Check your Medicare plan materials or contact your carrier directly for details about your appeal rights with Medicare Advantage and Part D prescription drug plans.

Danielle K. Roberts is a Medicare insurance expert and co-founder at Boomer Benefits, where her team of experts help baby boomers with their Medicare decisions nationwide.