Sometimes Medicare coverage is great and other times it is a challange. This is especially true when it comes to denials of coverage. If your client receives a denial, it’s essential to let them know they have the right to appeal. Understanding the Medicare appeals process can help your clients get the coverage they need. In this post, we provide a guide to help with this process.
Understand your coverage
One very important thing agents can do to help avoid denials of coverage; ensure clients understand their coverage. Discuss what each plan covers and what the beneficiary is responsible for such as copays, deductibles and coinsurance amounts. Licensed Medicare agents can help beneficiaries go over plan choices and ensure the beneficiary has the best coverage for their personal situation.
Agents can also discuss gaps in coverage and offer additional ways clients can cover themselves if anunexpected health problem comes up.
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Medicare Appeals
Medicare appeals are requests to review and reconsider decisions about healthcare coverage and payments. These appeals may be necessary when Medicare denies a beneficiarie’s request for a healthcare service, supply, or prescription drug, or refuses to pay for services they have received.
Click here to access appeals forms on CMS.gov
How to appeal a Medicare decision
Review the Notice of Denial
It is important to carefully read and understand the notice of denial before initiating an appeal. This document, often called either a EOB (explanation fo benefits) for Medicare advantage (Part C) or Part D plans or a MSN (Medicare summary notice) for Original Medicare, explains why coverage of the service or item was denied.
The plan must explain how to appeal the denial in writing. After the beneficiary files the appeal, the plan reviews its decision. If they do not agree with the appeal, an independent Medicare organization reviews the decision.
Understand Appeal Rights and Deadlines
There are very specific deadlines in place to file an appeal. The deadline varies by the type of Medicare coverage an beneficiary has.
Original Medicare (Part A and Part B)
The beneficiary has 120 days from the date they receive the MSN to file an appeal.
Medicare Advantage (Part C) and Prescription Drug Plans (Part D)
When a beneficiary of one of these plans wants to file an appeal, they have 60 days from the date they receive the EOB to file the appeal.
Collect Supporting documentation
Beneficiaries should gather any medical records, doctor’s notes, and any other evidence that supports their case. A healthcare provider is an invaluable resource to help provide documentation and expert opinions to help make the appeal successful.
If the beneficiary’s doctor agrees that they have are at serious risk, worsened by waiting, the plan must make a decision within 72 hours of receiving the request.
Click here to learn more about getting a fast appeal
Submit the appeal
The appeals process for Original Medicare and Medicare Advantage/Part D plans differs slightly.
For Original Medicare (Part A and Part B)
Fill out the redetermination request form included with the MSN or write a letter to the address listed on the MSN. It is important to include the beneficiaries’ name, Medicare number, the specific item or service in the appeal as well as any supporting documents. A Medicare contractor reviews the appeal.
For Medicare Advantage (Part C) and Part D (Prescription Drug Plans)
Appeals are submitted directly to the plan for reconsideration. The EOB has instructions on how to submit the appeals. If the initial appeal is denied, enrollees can request an independent review by a third-party organization.
Levels of Appeal
If the initial appeal is denied, there are many ways to escalate it.
- Request reconsideration by an independent review entity.
- If the amount in question reaches a specific threshold, you can request a hearing by an administrative law judge.
- If the beneficiary is dissatisfied with the administrative law judge’s decision, enrollees can request a Medicare appeals council review.
- If all else fails, the enrollee can file a lawsuit in federal district court.
Follow Up
Make sure beneficiaries keep copies correspondence or records related to the appeal. Always follow up on the status of the appeal and be sure to adhere to all deadlines.
Ensure a successful appeal
Be persistent; because appeals can take some time, it is important to be persistent. Don’t let initial denials discourage you.
Ask for assistance; use State Health Insurance Assistance Programs (SHIPs), which provide beneficiaries free assistance with Medicare appeals.
Organize all helpful information: it is essential to maintain a well-organized file of documents, correspondence, and any notes related to the appeal.
For help filing an appeal, contact the SHIP State Health Insurance Assistance Program.
Although Medicare denials and the appeals process may be discouraging, understanding the beneficiaries’ rights and the necessary steps makes the process manageable. Being thorough, organized, and persistent, improves the chance of a successful outcome for the appeal.
Understand your coverage
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