How the Medicare Appeals Process Works

A Step by Step Guide on Filing Your Medicare Appeal

Medical appeal Medicare appeals process

 

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Medicare does not cover everything, even when you think it will. Odds are you will face a coverage denial at some point in time. Understanding how the Medical appeals process works will not only save you time and frustration, it will also improve your chances of getting those services covered.

The Medicare Summary Notice

The Medicare Summary Notice (MSN) is a form you will receive quarterly (every three months) that lists all the Medicare services you received during that time, the amount that Medicare paid, and any non-covered charges, among other information. Please note that the MSN is sent to people on Original Medicare (Part A and Part B), not to people on Medicare Advantage. It is not a bill and may be sent to you from the company assigned to process your Medicare claim, not from Medicare itself.

When you find that Medicare has denied payment for a particular service, you may want to seek an appeal. However, the first thing you will want to do is reach out to your doctor's office for information. It is possible that the office did not use the proper ICD-10 diagnostic code. Correcting this could be sufficient to get coverage without having to go through the formal process of an appeal.

Next, you will want to check if you signed a Medicare Advanced Beneficiary Notice of Noncoverage (ABN) for the service in question. Contact your doctor's office and get a copy. If you did sign one, you may proceed to the next steps. If you did not, you are not eligible for a Medicare appeal.

Submitting a Medicare Appeal

You will want to gather any information that could support your appeal. This could mean reaching out to your medical provider for a letter of support, if appropriate, and getting copies of appropriate medical records. Be sure to include your Medicare number on all pages of any documents you plan to submit. Also, make a copy of all documents for your own records.

Medicare allows you to pursue an appeal in one of three ways:

  • Follow the appeals instructions included with your MSN and send a copy of the MSN and all requested documents to the company that processed your claim.
  • Complete the Centers for Medicare and Medicaid Services Redetermination Request Form and send it to the company that processed your claim.
  • Write a letter directly to the company that processed your claim that includes your name, Medicare number, denied service, and the reason why you are requesting an appeal.

The Five Levels of Medicare Appeals

There are five levels in the Medicare appeals process. If at any time your appeal is approved by Medicare, the process ends at the level you are currently on. If a denial is upheld, you will have to decide whether or not to proceed to the next level.

Level 1: Redetermination by the company that first processed your Medicare claim

The first step is to complete a Redetermination Request Form. You will get a Level 1 decision within 60 days. It could take an additional 14 days, however, if you submit additional information after the case was filed. If your claim is denied at Level 1, you have 180 days to proceed to the next level.

Level 2: Reconsideration by a Qualified Independent Contractor (QIC) 

If you did not succeed in a Level 1 appeal, you can complete a Reconsideration Request Form or send a written request to have a Qualified Independent Contractor review your case. You will get a Level 2 decision within 60 days, but if the QIC does not make their determination in time, you can request to proceed directly to Level 3. If the QIC denies your appeal, you have 60 days to request a hearing with a judge at Level 3.

Level 3: Hearing before an Administrative Law Judge (ALJ)  

You are only eligible for a Level 3 appeal if your case meets a minimum financial requirement, $160 of denied services in 2019. If you did not succeed in a Level 2 appeal, you can complete a Request for Medicare Hearing by an Administrative Law Judge (ALJ) Form or send a written request to the specific Office of Medicare Hearings and Appeals (OMHA) Central Operations listed on your Level 2 denial letter. In theory, you will get a Level 3 hearing within 90 days, but there is an unfortunate backlog in completing these cases.

In 2019, the wait for a Medicare appeal hearing was as long as 1,300 days. 

There is now a court order to clear the backlog by the end of 2022. If the ALJ does not make their determination in a reasonable amount of time, you can request to proceed directly to Level 4. If the ALJ denies your appeal, you have 60 days to request review with a Medicare Appeals Council at Level 4.

Level 4: Review by the Medicare Appeals Council (Appeals Council)

If you did not succeed in a Level 3 appeal, you can complete a Request for Review of an Administrative Law Judge (ALJ) Medicare Decision/Dismissal Form or send a written request to the Medicare Appeals Council to have them review the ALJ's decision. While the council could approve coverage for denied services, keep in mind they could also reverse parts of the ALJ's determination that you agreed with. There is no deadline for the Appeals Council to make a decision but you can request a Level 5 review if you feel a decision has not been made in a reasonable timeline. If the Medicare Appeals Council denies your appeal, you have 60 days to request a Level 5 review with a federal district court.

Level 5: Judicial review by a federal district court

You are only eligible for a Level 5 appeal if your case meets a minimum financial requirement, $1,630 of denied services in 2019. If necessary, you can combine claims to meet this dollar amount. A decision by a federal district court is final.

Other Types of Medicare Appeals

Medicare Advantage and Medicare Part D are run by private insurance companies and follow a slightly different Medical appeals process than does Original Medicare. Instead of an MSN, you will receive an Explanation of Benefits (EOB) or a Notice of Denial of Payment. There are five levels of Medicare appeals that are comparable to Original Medicare.

  • Level 1: Reconsideration by your health plan
  • Level 2: Review by an Independent Review Entity (IRE)
  • Level 3: Hearing before an Administrative Law Judge (ALJ)
  • Level 4: Review by the Medicare Appeals Council (Appeals Council)
  • Level 5: Judicial review by a federal district court

Medicare Advantage appeal levels parallel the timelines for Original Medicare. The timelines are considerably shorter for claims addressing Part D prescription drug coverage. A standard appeal request will be processed in seven days while an expedited requested will be completed within 72 hours at Levels 1 and 2. Levels 3 through 5 are the same for all types of Medicare appeals—Original Medicare, Medicare Advantage, and Medicare Part D.

A Word From Verywell

Medicare appeals can be tricky if you do not understand how the system works. Missing key deadlines, filling out inappropriate forms, supplying incomplete information, or sending documentation to the wrong location can all impact on your ability to process an appeal. Follow these steps and put your strongest case forward.

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Article Sources

  1. Average Processing Time By Fiscal Year. U.S. Department of Health and Human Services. Updated April 18, 2019.

  2. Wachler AB, Roumayah ED. OMHA Implements Expanded Dispute Resolution Process for Medicare Providers. American Bar Association. Published December 18, 2018.