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Caregiving

How to Appeal a Denied Medicare Claim

Take the following steps if you disagree with a decision made by Medicare.

Appealing a Medicare claim can be time-consuming and slow. Before going that route, talk with the doctor, hospital and Medicare to see if you can spot the problem and get the claim resubmitted. If you can't fix the problem that way, look on the back of the Medicare summary notice for the detailed appeal rules, and see the decision notice at each level of appeal for details about the information you need to submit.

You may need some extra paperwork to get permission to help your parent. You can call Medicare at 800-633-4227 and ask questions without your parents' specific permission, but your parents generally need to fill out an "Appointment of Representative" form for a family member, advocate, lawyer or doctor to file an appeal on their behalf (available at Medicare.gov). You may also have to get a medical information release form to get details from the hospital or providers about your parents' care.

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Traditional Medicare. There are five levels of claims appeals for traditional Medicare; most people have to go through several levels to get a denial overturned. At the first level, you are given 120 days after receiving the Medicare summary notice to request a "redetermination" by a Medicare contractor—that is, the person who reviews the claim. Circle the item you're disputing on the summary notice; then send any supporting information, such as an explanation of the problem and a letter from the doctor explaining why the charge should be covered. The claims reviewer assigned to your case will usually decide within 60 days of receiving your request.

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If the redetermination is denied, you can request reconsideration from a different claims reviewer and submit additional evidence. Reconsideration is usually decided within 60 days.

Still no luck? Disputes involving amounts less than $140 go no further. For charges of $140 or more, you can request a hearing with an administrative law judge. If you have to go to the next level, you can submit the claim for the appeals council to review. For amounts of at least $1,400, the final level of appeal is judicial review in U.S. district court.

Medicare Advantage and Part D. You have 60 days to initiate an appeal involving a Medicare Advantage or Part D prescription-drug plan. In both cases, you start by appealing to the plan, rather than to Medicare. Follow the plan's instructions on its explanation of benefits. Part D has fast-track appeals of 72 hours if your parent hasn't received the prescription and his or her health would be jeopardized by waiting. Otherwise, the plan must notify you of its decision within seven days.

See How Do I File an Appeal? in the "Claims & Appeals" section of Medicare.gov for more information about each type of appeal.

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