Appealing a Decision if You Have Been Denied Medicare Coverage

Calendar Icon Updated May 24, 2019
Medicare

If Medicare, your Medicare Advantage Plan (or other type of Medicare health plan), or your prescription drug plan denies you coverage for something you believe is necessary for your health, you can appeal the decision.

Things That Can Be Appealed

For example, you might want to file an appeal if your request for any of the following things is denied:

  • a particular health care service, certain supplies, a particular item, or a prescription drug that you believe should be covered that you think you should be able to get; or
  • payment for a health care service, certain supplies, a particular item, or a prescription drug you already received.

It’s also possible to make an appeal if Medicare or your plan quits providing or paying for all or part of a health care service, certain supplies, a particular item, or a prescription drug that you currently get and you believe you still need.

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The Appeals Process

For each part of the Medicare program (Part A, Part B, Part C, and Part D), the appeals process has five different levels. If you want to further appeal a decision made at any level of the process, you can usually go to the next level. (You’ll get instructions on how to move to the next level of appeal at each stage in the process.)

Filing An Appeal If You Have Original Medicare

Those who have Original Medicare (Medicare Part A and Part B) will receive what’s called a “Medicare Summary Notice” every three months in the mail, if you get Part A and Part B-covered items and services. This notice will show the items and services that providers and suppliers have billed to Medicare during the three-month period, what Medicare paid for, and what you may owe the provider or supplier.

The notice will also inform you if Medicare has fully or partially denied a medical claim. If you disagree with a decision, you can make an appeal. (The notice will have information about your right to appeal.) Should you decide to appeal, you should request any information that may help your case from your doctor, other health care provider, or supplier.

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The appeals process consists of five different levels:

Level 1: This level is a redetermination by the Medicare administrative contractor.

Level 2: The next level is reconsideration by a qualified independent contractor.

Level 3: The next level is a hearing before an administrative law judge.

Level 4: The next level is a review by the Medicare Appeals Council.

Level 5: The final level is a judicial review by a federal district court.

Filing An Appeal If You Have a Medicare Advantage Plan (or Other Health Plan)

Those who have a Medicare Advantage Plan or other Medicare health plan can request that the plan provide or pay for items or services that they believe should be covered, provided, or continued. Commonly, this is referred to as an “organization determination.”

If you want to appeal the plan’s initial decision (the organization determination), you have the right to file an appeal. You’ll receive a notice that explains why the plan fully or partially denied the request, along with instructions on how to appeal the decision.

Again, the appeals process has five levels:

Level 1: This level consists of a reconsideration from your plan.

Level 2: The next level is a review by an independent review entity.

Level 3: The next level is a hearing in front of an administrative law judge.

Level 4: The next level is a review by the Medicare Appeals Council.

Level 5: The final level is a judicial review by a federal district court.

Filing An Appeal If You Have Medicare Part D Prescription Drug Coverage

Those with Part D prescription drug coverage can ask their plan to provide or pay for a drug that they believe should be covered, provided, or continued. If the plan denies your request to pay for a drug, you can make an appeal.

Once again, the appeals process consists of five levels:

Level 1: This level consists of a redetermination from your plan.

Level 2: The next level is reconsideration by an independent review entity.

Level 3: The next level is a hearing in front an administrative law judge.

Level 4: The next level is a review by the Medicare Appeals Council.

Level 5: The final level is a judicial review by a federal district court.

If you want someone to help you with your appeal (such as a family member, friend, attorney, doctor, or someone else), you can appoint a representative to act on your behalf.

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