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The Process of Appealing a Medicare Decision 

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How To Appeal A Medicare Decision | Medicare Made Clear

When you visit your doctor, it’s normal to assume your statement and charges will be correct and accurate. That is not always the case, however. Sometimes the provider codes services incorrectly and Medicare doesn’t cover charges as they should. When errors like this occur, you may want to file an appeal. 

Every three months, Medicare sends a Medicare Summary Notice in the mail. The Medicare Summary Notice will show you all the supplies and services providers have billed Medicare for in your name. In the summary, there is section that says, “Service Approved?” with a place for “YES” or “NO.” If the summary says no for a service you believe should be covered, it’s time to take action. 

Original Medicare Appeal 

When Medicare denies an item or service, you will first want to contact your doctor’s office or health care provider to make sure that they have submitted the correct information for your visit. If not, the office may resubmit your claim. If you do not agree with the final decision from your doctor’s office, then you can file an appeal. Medicare can deny a claim for numerous reasons, so it’s important to hold on to any receipts and bills from your doctor visits so you can compare them to your summary notice. 

Medicare can only base its decision on the information provided. If you do not have receipts or other essential information to submit to Medicare, there is a chance that Medicare will deny the claim. 

On the back of the Medicare Summary Notice, there is a step-by-step guide explaining how to file an appeal. There are a total of five levels of appeals. Most beneficiaries will only need to complete level one. But if Medicare denies your appeal, you have the option of pursuing your claim all the way up to federal court depending on the amount of the claim.  

The first level of the appeal process is the Medicare Redetermination Request Form (CMS Form 20027). When sending this form to Medicare, be sure to attach any relevant supporting documents that help your case. Along with the form, write a letter explaining why you think that your claim should be covered. 

Note that an appeal for Original Medicare must be submitted within 120 days from the date indicated on the summary. 

Medicare Advantage Appeal 

If you are on a Medicare Advantage plan, then filing an appeal is somewhat different. Since your Medicare Advantage plan assumes Medicare’s responsibility for your coverage, the responsibility for a denial also falls on the plan. You need to file appeals for Medicare Advantage with the insurance company directly. 

If you find an error on your Summary Notice, ask your health care provider for any information that will help your appeal. You can refer to your insurer’s health plan materials or contact your insurance provider for  information on how to file an appeal. After receiving your Medicare Summary Notice, you, your doctor, or representative will have 60 days to submit your appeal request to your carrier. 

You can submit a written request for an appeal by supplying your Medicare ID number,  the items or services that you want to appeal, and the supporting documents that support your case. When writing your appeal, do not let emotions take over. A representative at the insurance company will be reading the letter and will be the one to determine the approval or denial of your claim. 

Depending on your situation, your carrier may take anywhere from 72 hours to 60 days to respond to an appeal. 

The process of appealing a Medicare decision can be tedious and time-consuming. The good news is that Medicare approves the vast majority of claims it processes and most people will never need to progress beyond the first level of appeal.