What Is the Medicare Appeal Process?
Patients have the right to appeal any decision about Medicare services. This is true regardless of whether the patient is enrolled in original Medicare, a Medicare managed care plan (Medicare Part C), or a Medicare prescription drug plan (Medicare Part D). The type of Medicare coverage will dictate the specific appeal filing process.
Medicare Part A and Part B Appeals
The patient can appeal if Medicare does not pay for or refuses to provide the patient with a necessary medical item (typically an item of "durable medical equipment") or medical service. The regulations governing the uniform Medicare Part A and Part B appeals processes are contained in 42 CFR Part 405 subpart I.
Filing an appeal requires knowledge of the complex, five-stage Medicare administrative appeals process.
STAGE ONE: Redetermination
A patient enrolled in original Medicare Part A or Part B can file an appeal if the patient believes Medicare should have paid for, or did not pay enough for, an item or service received. The patient's appeal rights are set forth on the back of the Explanation of Medicare Benefits or Medicare Summary Notice ("Notice"). This document, which is sent to patients via mail every three months, will explain the basis for the denial and describe the appeal procedure.
To start the redetermination process, a patient, or her representative, must do the following:
1. Write the received date on the notice. By recording the date the notice was received on the document, the patient or patient's representative can focus on the appeal due date.
2. Examine the notice closely and circle each questionable item.
3. Request medical records and additional information from the physician or medical care provider to support the medical necessity for the care, service or durable medical equipment. The patient or patient's representative will need to contact the medical records office for the medical care provider to formally request all records. Be certain to include that the medical records are requested to appeal a Medicare decision, and that there is a 120-day deadline for filing the appeal.
Medical records offices are notoriously slow. You may need to "be the squeaky wheel" to get the records. Keep in mind that the 120-day deadline is the patient's deadline and, as such, the busy medical records office has little incentive to comply with the records request quickly.
4. Write down the reason for appealing the denial on the notice itself. If there is not enough room to write the reason, use separate paper. The reason for writing the appeal on the notice itself is to make the process as uncomplicated and as clear as possible. The fewer papers for a bureaucrat to review, the better.
5. Add a contact telephone number on the notice itself. Again, the goal is to make the review as clear and simple as possible for the reviewer. If the reviewer has questions, the telephone number will facilitate resolution.
6. Sign the written appeal on the notice. Make a copy of the notice and all supporting materials relating to the written appeal for the patient's records, and send the originals to the Medicare contractor's address listed on the notice.
STAGE TWO: Reconsideration
A patient dissatisfied with a carrier's redetermination decision may file a request for reconsideration to be conducted by a Qualified Independent Contractor (QIC). This second level of appeal must be filed within 180 calendar days of receiving notice of the redetermination decision.
STAGE THREE: Administrative Law Judge
The third level of appeal is the Administrative Law Judge (ALJ) hearing. A provider dissatisfied with a reconsideration decision or who has exercised the escalation provision at the reconsideration stage may request an ALJ hearing. The request must be filed within 60 days following receipt of the QIC's decision.
STAGE FOUR: Medicare Appeals Council
The fourth level of appeal is the Medicare Appeals Council (MAC) Review. The MAC is within the Departmental Appeals Board of the U.S. Department of Health and Human Services. A MAC Review request must be 60 days following receipt of the ALJ's decision.
STAGE FIVE: Judicial Review in Federal Court
A request for review in district court must be filed within 60 days of receipt of the MAC's decision. In a federal district court action, the findings of fact by the Secretary of HHS are deemed conclusive if supported by substantial evidence.
http://www.medicare.gov/basics/appeals.asp
Medicare Part C Appeals
Medicare Part C is also known as "Medicare Advantage." Under this type of Medicare managed care plan, the patient can file an appeal if the plan will not pay for, does not allow, or stops a service that the patient believes should be covered or provided. Filing an appeal is more complicated when filed under the Medicare Advantage plans because the patient or patient's representative must comply with rules and procedures from both the federal government (Medicare) and the private insurance company that administers the Medicare Part C program.
A "fast decision" should be requested in situations where a normal waiting period would jeopardize the patient's health. The plan must answer a "fast decision" request within 72 hours.
Each Medicare Advantage plan has its own appeal process and they must clearly set forth the process. Steps:
STAGE ONE: Organizational Determination
The initial review process for Part C Medicare Managed Care can be either "standard" where a preservice determination must be made within 14 days or "expedited" where a preservice determination will be made within 72 hours.
STAGE TWO: First Level Appeal
Patient or patient's representative has 60 days from the date of receipt of initial denial to file a written appeal.
STAGE THREE: Second Level Appeal (Automatic Independent Review if Plan Upholds Denial)
If the plan denies the appeal, the appeal is reviewed by an independent organization that works for Medicare, not for the plan. Since this is an automatic review, there is no filing time deadline.
STAGE FOUR: Third Level Appeal (Not Automatic, Review by ALJ)
This level of appeal must be filed within 60 days from the date of receipt of independent reviewer's denial and it is filed with the Administrative Law Judge (ALJ), Office of Medicare Hearings and Appeals. The amount in controversy must be in excess of approximately $120, an amount that is adjusted with the medical care component of the Consumer Price Index. There is no statutory time for the appeal to be processed by the ALJ.
STAGE FIVE: Fourth Level Appeal (Not Automatic, Review by MAC)
This appeal is filed within 60 days of the Third Level denial and is filed with the Medicare Appeals Council. There is no statutory time limit for the MAC to process the appeal.
STAGE SIX: Fifth Level Appeal (Not Automatic, Review by Federal Court)
This appeal is filed within 60 days of the Fourth Level denial and is filed with the Federal District Court. The amount in controversy must be in excess of approximately $1,220, an amount that is adjusted with the medical care component of the Consumer Price Index.
http://www.cms.hhs.gov/MMCAG
Medicare Part D Appeals
If the patient participates in a Medicare prescription drug plan, an appeal may be directed at the plan sponsor's decision not to provide or pay for a Part D prescription drug that the patient believes the plan sponsor should provide, pay for or reimburse the participant for. Many different private companies administer Medicare Part D Prescription Plans. Each plan must set forth in writing request an appeal. The appeal processes differ based on the specific Medicare Prescription Drug Plans that are administered by outside insurance companies with their own rules.
Steps for Appealing Denial of Medicare Part D Benefit:
STAGE ONE: Consider Substitute Drug That Is Covered. Communicate with the prescribing physician about the situation to determine whether a different and equally effective drug is covered by the plan.
STAGE TWO: Physician Provides Written Explanation of Need for Medication. If there is no alternative drug, request that the physician write an explanation about why the patient needs this particular drug. Specificity is key. Either the patient or the prescribing physician can submit the request to the Medicare drug plan. The requests are typically answered within three days. If necessary, the patient can request a faster decision.
STAGE THREE: Standard Written Appeal. If the denies the written request for the prescription, the next step is to file a formal appeal. Each Medicare Part D participating company has its own rules for appealing an adverse decision. As such, it is imperative to find out how the appeal process works in the specific drug plan. The appeal must be submitted within 60 days of the denial of the physician's written explanation. The plan must respond to the patient's appeal within one week.
If the patient requests a standard appeal, the plan sponsor must provide the answer within seven calendar days after receiving the appeal. If the patient or patient's physician believes that the patient's health could be seriously harmed by waiting up to seven calendar days for a decision, the patient or physician can ask the plan sponsor for a fast appeal. If the request is approved, the plan sponsor must answer you within 72 hours.
Patients can obtain assistance in filing the appeal by contacting the state's State Health Insurance Assistance Program (SHIP)
STAGE FOUR: Second Level Appeal. If the drug company denies the appeal, the patient can appeal again. The second appeal is reviewed by an independent organization that works for Medicare. Each independent insurer has its own instructions on file further Medicare appeals. If the Medicare prescription drug plan doesn't respond to the patient's request, a grievance can be filed by calling 800-MEDICARE.
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