Many retirees face challenges when their Medicare claims are denied. Understanding the appeals process can help you recover denied benefits. If you receive a denial, it is essential to know that many appeals are successful. Taking the right steps can increase your chances of reversing the decision.
Understanding the Appeal Process
First, it is advisable to communicate with your healthcare provider and Medicare. Often, denials arise from simple billing code errors. By discussing the issue with your doctor or hospital, you may identify and resolve the problem before proceeding with an appeal.
If initial discussions do not resolve the issue, you can formally appeal the denial. For those on original Medicare, begin by reviewing your quarterly Medicare Summary Notice (MSN). This document details the services billed to Medicare and explains the reasons for any denial. You can also check your Medicare claims online at MyMedicare.gov or by calling 800-633-4227.
The appeal process for original Medicare involves five levels. You have 120 days from receiving the MSN to request a “redetermination” by a Medicare contractor. To initiate this process, circle the disputed items on the MSN, provide a written explanation for your appeal, and include any supporting documents, such as a letter from your doctor. Send this information to the address listed on the form.
Levels of Appeals and Timelines
You may also opt to use the Medicare Redetermination Form, which can be downloaded from CMS.gov or obtained by requesting a copy via phone. Typically, the contractor will make a decision within 60 days of receiving your request. If the redetermination is denied, you can request a reconsideration by a different claims reviewer and submit additional evidence. If the disputed charges exceed $190 in 2025, you may request a hearing with an administrative law judge. This hearing generally occurs via videoconference or teleconference.
Should the need arise to escalate your appeal further, you can appeal to the Medicare Appeals Council. For claims exceeding $1,900 in 2025, the highest level of appeal is judicial review in a U.S. District Court.
For those enrolled in a Medicare Advantage health plan or Part D prescription drug plan, the appeals process varies slightly. It is crucial to initiate your appeal within 65 days directly with the private insurance plan. If you believe your health is at risk due to the plan’s refusal, you can request an expedited appeal. Part D insurers must respond within 24 hours, while Medicare Advantage plans must provide an answer within 72 hours.
Similar to original Medicare, the appeals process for these plans consists of five levels. Each level allows for further appeal if you disagree with the decision made.
Resources and Assistance
For detailed guidance on the appeals process, visit Medicare.gov/claims-appeals. It is also essential to keep copies of all communications regarding your denial, whether written or oral.
If you require assistance with your appeal, consider appointing a representative such as a trusted friend, family member, or advocate. Additionally, you can contact your State Health Insurance Assistance Program (SHIP) for free support. To locate your local SHIP, visit ShipHelp.org or call 877-839-2675.
By following these steps and utilizing available resources, you can navigate the Medicare appeals process with greater confidence and clarity.
