“If you disagree with the full or partial denial of a claim, you must file an appeal within 120 days of getting the MSN. Complete a Redetermination Request Form and send it to the Medicare contractor at the address provided on the MSN.”
You do not just have to accept it, if Medicare wrongly denies coverage or payment for a Part A (hospital insurance) or Part B (outpatient services) request. You can file an appeal. Here is how to appeal your Medicare Parts A or B denial.
You can appeal up to five levels of review, if you disagree with Medicare’s decision about:
- How much you must pay for a service or item
- Reimbursing you for a service or item you already bought
- Your request for a service or item
- Discontinuing a service or item
When you appeal, talk to your physician, health care provider or medical item supplier for whatever information they think might help you. It will benefit them and you, if Medicare grants your request.
Five Levels of Appeals
The five levels of review of a Medicare Part A or Part B denial are:
- Find the Medicare Summary Notice (MSN) that references the disputed service or item. You get an MSN every three months. It shows every service and item that providers billed to Medicare during those three months. The MSN will state whether Medicare denied your claim. If you disagree with the full or partial denial of a claim, you must file an appeal within 120 days of getting the MSN. Complete a Redetermination Request Form and send it to the Medicare contractor at the address provided on the MSN.
- If you disagree with the decision of the Medicare contractor, you can request a reconsideration by a Qualified Independent Contractor (QIC).
- If you do not agree with the result from the QIC, you can request a hearing with an Administrative Law Judge (ALJ).
- If you are dissatisfied with the decision of the ALJ, you can request a review from the Medicare Appeals Council.
- Finally, if you feel the Appeals Council reached the wrong result, you can file for judicial review in a federal district court. The district courts are the trial level of the federal courts.
The appeals process discussed above applies to Original Medicare. Other types of Medicare plans may follow a different procedure. If a Medicare plan is not Original Medicare, look on your Medicare card for information on where to get appeals instructions.
Sometimes, you cannot wait to go through the long, drawn-out appeals process. If you are about to be discharged from the hospital and you feel it is too soon, you can get an immediate review of the decision. If you ignore the rules for fast appeal precisely, it can cost you hundreds of dollars or more.
To prevent a premature hospital discharge, you can contact the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) in your area. The BFCC-QIO also handles appeals of decisions to end outpatient services.
The posting discusses the general law. It is always best to talk with an elder law attorney in your area, since the laws are different in every state.
Medicare.gov. “How do I file an appeal?” (accessed November 6, 2017) https://www.medicare.gov/claims-and-appeals/file-an-appeal/appeals.html
Medicare.gov. “Getting a fast appeal in a hospital.” (accessed November 6, 2017) https://www.medicare.gov/claims-and-appeals/right-to-fast-appeal/hospital/fast-appeals-in-hospitals.html
Medicare.gov. “Getting a fast appeal from non-hospital settings.” (accessed November 6, 2017) https://www.medicare.gov/claims-and-appeals/right-to-fast-appeal/non-hospital/fast-appeals-non-hospital-setting.html
Medicare.gov. “Medicare Redetermination Request Form – 1st Level of Appeal.” (accessed November 7, 2017) https://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS20027.pdf