Medicare Appeals Process

If Medicare has denied a service, prescription drug or durable medical equipment, you have the right to appeal this decision. In addition to that, if Medicare releases you from the hospital or a skilled nursing facility, you can appeal this as well. You can appeal anything that is denied within your Medicare Part A, Part B, Part C or Part D benefits.

How Do You Appeal a Service Denied by Medicare?

You begin the appeals process with your Medicare Summary Notice or MSN. The MSN explains where your recent request for services stands. If Medicare denies a claim, you can submit a Redetermination Request form to the company that is listed on the last page of your MSN. If you prefer, you may write a letter to Medicare requesting an appeal.

If you decide to write a letter, you will need to make sure that you add the following information:

  • Name and address.
  • A copy of your Medicare Summary Notice with the disputed items circled.
  • Your reason for believing that the items you circled must be covered.
  • If you are going to appoint someone to handle the appeal for you, you must give this person’s name.
  • Doctor’s notes, medical records and any other documentation that may help your case.

Appealing Decisions of Medicare Advantage

If you are appealing a decision from Medicare Advantage, the process will be a lot like the one described above, but you would file your claim with your plan. The explanation of benefits or the notice of denial will inform you of what you need to do going forward.

Appealing Denials of Prescription Drugs

If you need to appeal the denial of prescription drugs, write a request to your prescription drug plan. If you have already paid for the drug in question, you may still appeal Medicare’s denial. If you never received the prescription drug, you can appeal the denial in this instance as well.

How Long Does the Appeals Process Take?

In most cases, you will receive a decision in approximately two months. The notice you receive will be a “Redetermination Notice,” and you will get it with a letter or a MSN.

If you are appealing a decision made by Medicare Advantage, you will only need to wait two weeks in most cases. The prescription drug appeals process takes even less time. You usually receive an answer within 72 hours.

You are entitled to file an expedited appeal if you are disputing a hospital discharge. You can also file this type of appeal if Medicare decides to suddenly stop paying for a service that was covered previously.

What Happens if Your Medicare Appeal Is Approved?

If Medicare or Medicare Advantage approves your appeal, Medicare will pay the amount that was approved for it to pay. You don’t have to do anything after this point.

What if Your Appeal Is Denied?

If Medicare or Medicare Advantage denies your appeal, you may appeal this denial and subsequent denials as well. The company that first denied your claim will also be the company that decides on your appeal, but subsequent appeals will be heard by third parties.

If you need to appeal a decision by Medicare or Medicare Advantage, the first thing that you must do is know what your Medicare rights are. This will give you the best chances of obtaining payment for your services.