How to Appeal a Medicare Decision

Published by: Medicare Made Clear

You may file an appeal if you disagree with a coverage or payment decision made by Medicare or by your Medicare health or prescription drug plan. You may appeal if you receive a denial any of the following:

 

  • A health care service, supply, item or prescription drug that you think you should be able to get or continue to get
  • Payment for a health care service, supply, item or a prescription drug you already got
  • Request to change the amount you must pay for a health care service, supply, item, or prescription drug

 

The appeals process has five levels. The first level asks Medicare or your Medicare health or prescription drug plan for a “redetermination” on the original request. If your first-level appeal is denied, you may appeal to the next level and the next. The fifth-level appeal, if you reach it, is decided by a judicial review in a federal district court.

 

 

Filing an Appeal with Medicare

 

You can file a first-level appeal for coverage or payment denied by Medicare by completing a Redetermination Request Form. You must file your appeal within 120 days of receiving the Medicare Summary Notice (MSN) that first reported the service or item.

 

Send the completed form to the Medicare contractor at the address listed in the Appeals Information section of your Medicare Summary Notice (MSN) you receive from Medicare. You may also follow the instructions on the back of your MSN and file an appeal without completing the form.

 

Generally, you get a decision within 60 days. The decision is called a “Medicare Redetermination Notice.” It may come as a separate notice or it may be included in a future MSN. The notice will explain the decision and what you can do to appeal to the next level.

 

 

Filing an Appeal with a Private Medicare Plan

 

If you receive an “organization determination” that denies all or part of a request for coverage or payment, you may file an appeal for reconsideration with your plan provider. You must file the appeal within 60 days of the determination date.

 

You or a representative must submit a written reconsideration request to your plan. Check your plan details for information about appeals specific to your plan.

 

In general, the request should include:

 

  • Your name, address, and the Medicare number shown on your Medicare card
  • Description of the items or services for which you’re requesting a reconsideration, including the dates of service and the reason for your appeal
  • The name of your representative, if you’ve identified one, and proof of representation

 

You may also include any other information or documentation that may support your request, including anything your doctor or another provider may provide.

 

Standard service requests must be decided within 30 days. Payment requests must be decided within 60 days. You or your doctor may ask for a faster decision (72 hours) if waiting may seriously threaten your life, health or ability to regain maximum function.

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