If you have Medicare, you have rights. You have the right to receive medical care, services, procedures and items that are medically necessary. Should Medicare deny coverage for anything that you or a physician feels is medically necessary, there is an appeals process. It’s a fairly quick and painless procedure, and 80%-90% of those appealing Medicare decisions end up winning on appeal.
The specific Medicare appeals process is dependent upon the type of Medicare coverage that the patient has:
Original Medicare
Your appeal rights are on the back of the Explanation of Medicare Benefits or Medicare Summary Notice that is mailed to you from a company that handles bills for Medicare. Follow the instructions and make sure to appeal immediately.
Managed Care Medicare
If you are in a Medicare managed care plan, you have the same rights to an appeal as with original Medicare. If you think your health could be seriously harmed by waiting for a decision regarding a service, ask the plan for a fast decision. The plan must answer your request within 72 hours.
The Medicare managed care plan must tell you in writing how to appeal. If the plan denies your appeal, you may have an independent organization that works for Medicare review the decision.
Going up the Ladder
If Medicare appeals are denied, and you and your physician feel that the care, procedure or item is medically necessary, there are several levels of the appeals process for denials;
- Redetermination
- Reconsideration
- Administrative Law Judge Hearing
- Medicare Appeals Council (MAC)
- Federal District Court
Make sure to follow the instructions for the appeals process carefully and within the proper time limits. Keep copies of all documents and make notes of all telephone conversations. With a little determination and good recordkeeping, you may very well prevail in the Medicare appeals process.
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