How to Appeal a Claim Denied by Medicare

Medicare is a medical insurance program administered nationally by the Centers for Medicaid and Medicare Services, a part of the U.S federal government working under the Social Security Administration. The program is divided into part A to D, and one has to be a permanent U.S citizen for at least five years to be eligible for either. For part A and B, the criteria are that you have to be aged 65 years and above and qualify for Social Security support. You can also enter the program if you are below 65 years but be permanently disabled and have been receiving disability benefits for at least two years or be suffering from the end-stage renal disease.

Part C, also known as Medicare advantage is procured from private insurers, but to qualify, one has to be already enlisted in part A or B. Part D also available from private insurers caters for prescriptions drugs and is also available to people subscribed to part A or B.

Appealing a Medicare Decision

Steps and Procedures for Appealing a Denied Application

Determine if an Appeal is Appropriate

If you've already submitted your application for Medicare and are receiving benefits but your medical bill was denied for coverage, you may want to consider an appeal. Appeals are actions taken in the event of a disagreement with the coverage or payment decision arrived at by Medicare. You have the right to appeal to any of the four parts of Medicare if:

  • It denies your request for a health care service, supply, or drug that you feel you should be able to access.
  • A change of the amount you should pay for health care services; prescription drugs, supplies or items is denied, OR,
  • A request for payment of a health care service, item, supply or prescription medication that you already have is rejected.

Evaluate your Medical Summary Notice

Appealing starts by evaluating the Medical Summary Notice (MSN) sent to your mail every three months. It indicates all the services and supplies that providers billed to Medicare in a quarter. From the MSN, you can determine the amount paid by Medicare and what is denied. It is usually an initial determination made by the company that handles bills for Medicare.

Appealing the Decision

The initial judgment can be appealed by either;

  • Filling out a Redetermination Request Form and sending it to the contractor handling your case indicated on the MSN
  • Adhere to the instructions for appealing as shown on the MSN. You may need to consult your doctor or healthcare provider on information that may be helpful to your case.
  • Making a written request to the organization that handles the claims of Medicare (the information can be seen on the MSN at the Appeals Information section. The petition has to explain as to why you do not agree with the initial determination and the specifics for which you require to be predetermined.

Your name, address, phone number and Medicare number have to be provided on a signed form. All the documents submitted for the appeal request have to have the Medicare number indicated on them. Additional information or supporting evidence can be provided after the initial redetermination request has been filed.

Medicare Treatment

What to Expect After Filing an Appeal?

UnitedHealthcare reviews all submitted appeals before elapsing of 60 calendar days from the date of receiving the MSN. It takes roughly 30 days to process claims. However, if additional information is submitted after the initial appeal, it can take an extra 14 days. One can file for an expedited decision in situations that are time sensitive. The expedited process is used when the standard timeframe for making decisions might seriously jeopardize your health. Such decisions are made within a maximum of 72 hours.