Yes, You Can Appeal a Medicare Payment or Coverage Decision. Here’s How
Key takeaways:
You can appeal payment and coverage decisions made by original Medicare, a Medicare Advantage plan, or a Part D prescription drug plan, if you disagree with them.
The appeals process can include escalating levels that may require reviews by an independent contractor, an administrative law judge, and a federal judge.
You can seek help from your healthcare providers, your State Health Insurance Assistance Program, and Medicare-focused advocacy groups.
If you disagree with a Medicare payment or coverage decision, there’s good news: You can appeal. The process can be time-consuming, but if you stay organized and persistent, there’s a reasonable chance the decision will be overturned fully or in part. In fact, a recent federal analysis of Medicare Advantage appeals by providers and enrollees showed that 3 out of 4 decisions were partially or fully overturned when disputed.
What types of Medicare decisions can I appeal?
You have the right to dispute decisions from Medicare, a Medicare health plan, or a Medicare Part D prescription drug plan that involve:
A request for a healthcare service, supply, item, or prescription drug you believe you are eligible to receive
A request for payment of a healthcare service, supply, item, or prescription drug that you have received
A request to change the amount you are required to pay for a healthcare service, supply, item, or prescription drug
A situation where Medicare or a Medicare plan stops providing or paying for all or part of a healthcare service, supply, item, or prescription drug you believe you still need
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Advocates encourage consumers to appeal every denial. Medicare has an official government booklet that explains the appeals process in detail.
How do I start the appeals process?
Where you begin in the appeals process depends on the nature of your Medicare problem and the urgency of the needed solution.
One place you can start is by appointing a representative. You can have a trusted relative, friend, advocate, attorney, doctor, or someone else file an appeal on your behalf by completing an Appointment of Representative form or submitting a written request that includes specific information that can be found here.
How do I appeal if I have original Medicare?
Original Medicare includes Part A (hospital insurance) and Part B (medical insurance).
Medicare Part A includes:
Inpatient hospital care
A limited stay at a skilled nursing facility after hospitalization
Some home healthcare
Hospice care
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Medicare Part B pays for services, vaccines, and medications not covered under other parts of Medicare.
Original Medicare enrollees receive a Medicare summary notice (MSN) in the mail every three months. This statement details items and services that suppliers billed to Medicare each quarter, what Medicare paid, and what you may owe. The MSN also shows whether Medicare has approved, fully denied, or partially denied your medical claim. This is an initial determination made by the Medicare Administrative Contractor (MAC) that processes Medicare claims.
You are entitled to an expedited appeal, or fast appeal, if you think you’re being discharged too soon from a Medicare-covered inpatient hospital stay. If you ask for an appeal in writing or by phone no later than the day you’re scheduled to be discharged, you can remain in the hospital without paying for the additional time (except for coinsurance or deductibles) while you wait for a decision from the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO). You must ask the BFCC-QIO for a fast appeal by noon the day before the coverage termination date for a Medicare-covered skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility, or hospice services you think are ending too soon.
What are the five levels in the appeals process for original Medicare?
The five levels in the appeals process for Original Medicare are:
Level 1: Redetermination by the Medicare Administrative Contractor (MAC)
A redetermination can be requested in several ways but always in writing. You will generally receive a decision from the MAC within 60 days after your request is received. If you disagree with the redetermination decision, you have 180 days after receiving the notice to request a reconsideration.
Level 2: Reconsideration by a Qualified Independent Contractor (QIC)
A QIC is an independent contractor that did not participate in the level 1 decision. You can request a reconsideration in several ways, including by filing a Medicare Reconsideration Request form. If you disagree with this decision, you have 60 days after receiving the notice to request a level 3 decision.
Level 3: Decision by the Office of Medicare Hearing and Appeals (OMHA)
This appeals level can involve a hearing before an Administrative Law Judge or a review of the record by this type of judge or an attorney adjudicator. If you disagree, or if there is not a timely decision, you can request a level 4 review.
Level 4: Review by the Medicare Appeals Council
If you disagree, or if there is not a timely decision, you can ask the Appeals Council to move your case to the next level.
Level 5: Judicial Review by a Federal District Court
To receive a review, cases must meet a minimum dollar amount remaining in dispute. In 2021, that minimum dollar amount is $1,760.
How do I appeal if I have Medicare Advantage?
Medicare Advantage plans — also known as Part C — which bundle Medicare Parts A, B, and, usually, D together, are alternative ways to get Medicare benefits. Medicare Advantage plans are sold by private insurers that Medicare approves. Just like with original Medicare, you have the right to ask these plans to provide or pay for items or services you think should be covered, supplied, or continued. This request begins the appeals process for Medicare Part C. The plan’s decision is called an organization determination.
In some cases, your treating doctor can begin a dispute by requesting an organization determination or certain pre-service reconsiderations without being appointed as your representative. If the doctor needs to pursue a higher level of appeal, you will need to submit an Appointment of Representative form. There are provisions in the law for a standard or fast appeal.
This appeals process follows five levels that are similar, but not identical, to original Medicare:
Level 1: Reconsideration from the plan
Level 2: Reconsideration determination by an Independent Review Entity (IRE)
Level 3: Decision by the Office of Medicare Hearings and Appeals (OMHA)
Level 4: Review by the Medicare Appeals Council
Level 5: Judicial review by a federal district court
How do I appeal if I have a Medicare drug plan?
Prescription drug coverage is available as an add-on to original Medicare called Medicare Part D, or as a prescription drug benefit included with a Medicare Advantage plan or other Medicare plan.
You have the right to ask the plan to provide or pay for a drug you think should be covered, supplied, or continued. You also have the right to appeal if you disagree with your plan’s decision about whether to provide or pay for a medication.
First, ask your prescriber if you meet prior authorization or step therapy requirements. You can also ask to substitute cheaper brand-name, generic, or over-the-counter drugs that work, as well.
Another option is the preliminary dispute process. You, your representative, your doctor, or other prescriber can request a standard coverage determination, including an “exception” to the plan formulary or coverage rules. If you haven’t already paid for the drug out of pocket, you can ask for a fast coverage determination — which can be made with a phone call — for a decision within 24 hours of your request.
Your drug plan will send a written decision. If you disagree, you can initiate a five-level appeals process.
Level 1: Reconsideration from the plan
Level 2: Reconsideration determination by an Independent Review Entity (IRE)
Level 3: Decision by the Office of Medicare Hearings and Appeals (OMHA)
Level 4: Review by the Medicare Appeals Council
Level 5: Judicial review by a federal district court
How do I maximize my chances of winning an appeal?
There are several ways to increase your chances of winning an appeal, including:
Closely following the directions for the specific appeals process that applies to your claim
Always writing your Medicare number on all documents submitted with an appeal request
Keeping a copy of everything you send to Medicare, a Medicare Administrative Contractor, or your Medicare health plan
The most important tip is to file a claim. Medicare appeals can only have success if they are filed. A 2018 federal report found that healthcare providers and Medicare enrollees appealed only 1% of Medicare Advantage reimbursement and pre-authorization denials between 2014 and 2016.
During that same period, 75% of the Medicare Advantage appeals reviewed had their initial decisions overturned. Specifically, 70% of appeals were fully successful and 5% were partially successful.
In this analysis, making an appeal was a worthwhile effort, because only 1 in 4 original decisions remained unchanged.
Appeals are important to ensuring you receive the care you need and that you receive all of the coverage to which you are entitled. The U.S. Department of Health and Human Services (HHS) Office of Inspector General’s report said that because Medicare beneficiaries and their providers rarely used the appeals process, the “beneficiary may have gone without the requested service, the beneficiary may have paid for the service out of pocket, or the provider may not have been paid for the service.”
How do I check the status of a claim?
You can check the status of a level 3 claim filed with the Office of Medicare Hearings and Appeals (OMHA) by visiting the ALJ Appeal Status Information System (AASIS) page.
Where can I find help for my Medicare appeal?
In addition to consulting your provider, the Centers for Medicare & Medicaid Services (CMS) offers many online Medicare resources for appeals. CMS also provides a Medicare telephone helpline at 1-800-MEDICARE (1-800-633-4227).
Your state and some territories have a State Health Insurance Assistance Program (SHIP) that offers free, personalized health insurance counseling, including assistance with appeals. In addition, there are independent advocacy groups that help Medicare enrollees navigate appeals and other issues. These organizations include the Medicare Rights Center, which offers counseling through a national telephone helpline at 800-333-4114 for people pursuing Medicare appeals, and the Center for Medicare Advocacy, which provides self-help toolkits for enrollees working on appeals.
The bottom line
Medicare appeals can help you receive payment or coverage for a needed healthcare service, supply, item, or prescription drug. Follow the appeal processes as directed for your specific dispute to get the best results. Seek help if you need it from your healthcare provider, a personal representative, Medicare, your State Health Insurance Assistance Program, or an advocacy group to navigate the appeals system.
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References
Center for Medicare Advocacy. (n.d.). Center for Medicare advocacy.
Center for Medicare Advocacy. (n.d.). Self help materials.
Centers for Medicare & Medicaid Services. (2020). Medicare reconsideration request form — 2nd level of appeal.
Centers for Medicare & Medicaid Services. (2021). Appointment of representative.
Centers for Medicare & Medicaid Services. (2022). Medicare appeals.
Medicare.gov. (n.d.). Appeals if you have a Medicare health plan.
Medicare.gov. (n.d.). Can someone file an appeal for me?
Medicare.gov. (n.d.). Drug plan coverage rules.
Medicare.gov. (n.d.). Filing an appeal if I have Original Medicare.
Medicare.gov. (n.d.). 5 things to know when filing an appeal.
Medicare.gov. (n.d.). How do I file an appeal?
Medicare.gov. (n.d.). "Medicare summary notice" (MSN).
Medicare.gov. (n.d.). Your right to a fast appeal.
Medicare Rights Center. (n.d.). Counseling & advocacy.
Medicare Rights Center. (n.d.). Medicare rights center.
State Health Insurance Assistance Program. (n.d.). SHIP.
U.S. Department of Health and Human Services. (2017). Appeals to the Medicare Appeals Council (Council).
U.S. Department of Health and Human Services. (2018). Medicare Advantage appeal outcomes and audit findings raise concerns about service and payment denials.
U.S. Department of Health and Human Services. (2022). ALJ appeal status information system inquiry page.
