What is a Medicare Appeal?
Sometimes, beneficiaries’ insurance plans can deny them coverage. A Medicare appeal is the action they can take if they disagree with a decision or payment by their Medicare plan. Beneficiaries can appeal if their Medicare plan denies them the following:
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A request for a health care item, supply, service, or drug that the beneficiary thinks that Medicare should cover.
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A request for a payment for a service, supply, drug, or health care item that the beneficiary already received.
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A request for a change of the amount the beneficiary must pay for the service, supply, drug, or health care item.
How to File an Appeal:
A beneficiary can start their appeal process through their plan if they have a Medicare Health Plan. The following are generic directions to follow to begin an appeal:
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The beneficiary, their representative, or their doctor will ask for an appeal within 60 days of the date of the coverage decision. If the deadline is missed, a reason for the delay must be provided.
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Include the following required information in the written appeal:
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The beneficiary’s name, address, and the Medicare Number on their Medicare card [JPG]
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The items or services for which they’re requesting a reconsideration, the dates of service, and the reason(s) why they are appealing.
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The name of the beneficiary’s representative and proof of representation, if applicable.
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Any other information that may help the beneficiary’s case.
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Beneficiaries can request a fast or expedited decision from their appeal if they think their health could be seriously harmed by waiting the standard 14 days for a decision. This means that the plan must provide a decision within 72 hours of their receipt of the appeal if they agree that the beneficiary’s health would be seriously harmed by waiting the time period for the standard decision.
- Submit online. Click here to begin.
How long an insurance plan has to respond to a beneficiary’s Medicare appeal depends on the type of request:
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Expedited (fast) request—72 hours
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Standard service request—30 calendar days
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Payment request—60 calendar days
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