If you have a Medicare Advantage plan and were denied coverage for a health service or item, you may choose to appeal the decision with your plan’s provider. The appeal process requires documentation for why the service or item should be covered under your plan, and it can take some time to go through the the levels of approval. Here is a quick breakdown of how the process works to file an appeal for a denial from a Medicare Advantage plan.
How Do I Know if I Was Denied Coverage or Payment?
If you have scheduled your health care service, but not yet received the medical care, your Medicare Advantage plan might send an advance Notice of Denial of Medical Coverage. If you have already received your medical service or item, your plan might send a Notice of Denial of Payment and/or an Explanation of Benefits denying coverage.
These notices are not bills, but they do contain explanations of what was covered and what is not being covered by your plan. You should read your notice of denial carefully to help understand why your plan is denying coverage for that particular service or item. If you feel like you do not understand why the service or item was denied, you should call your plan directly to ask why. Denials can sometimes be billing or coding errors, and your plan can help clarify over the phone if the notice letter is not clear.
If you receive a Notice of Denial or Explanation of Benefits (EOB) that states that a medical service was not or will not be paid for by your plan, you should consider starting the Medicare appeal process.
How Do I File an Appeal for a Denial of Coverage?
Your Notice of Denial or EOB should include instructions on how to file an appeal. It is important to follow the appeal instructions for your plan carefully in order to have the best chances of your appeal being approved.
Most initial appeals need to be filed within 60 days of the date on the denial notice. If you miss your appeal filing deadline, you may be eligible for a good cause extension. You will most likely need to send a letter with the appeal explaining why the service or item was necessary. It might be helpful to get a letter of support from your doctor or care provider as well to provide additional explanation for your appeal.
Once received, your Medicare Advantage plan should make a decision within 60 days. If you have not yet received your medical service or item, your Medicare Advantage plan might make a decision sooner, within 30 days (or 72 hours for expedited service).
You should receive a written letter back from your Medicare plan with the appeal decision. If your appeal is successful, your service or item will be covered. If your appeal is denied, you will have the opportunity to forward your appeal to the next level.
What if my Medicare Appeal is Denied?
If your initial appeal is denied by your Medicare Advantage plan, it will automatically be forwarded to the Independent Review Entity (IRE) for the next level of appeal. You will receive a new notice of denial from your plan if this is the case.
An IRE is a separate organization with which Medicare Advantage and Part D plans contract to handle the second level of appeals for denial of coverage. The IRE will review your appeal again, and typically make a decision within 60 days of the date on the plan denial notice.
If your appeal to the IRE is approved, your service or item will be covered. If the IRE appeal is denied, you might still be able to move your appeal up to the next level if your care or service is worth at least $180 (according to 2021 regulations). If your care is worth $180 or more, and your IRE appeal is denied, you have the option of submitting your appeal to the Office of Medicare Hearings and Appeals (OMHA).
You must file your appeal to OMHA within 60 days of the date on your IRE denial letter. If you reach this level, it might be beneficial to contact an attorney or legal services to help with your continued appeal. If your appeal to OMHA is denied, you will have the opportunity to appeal to the Council within 60 days. If the Council still denies your appeal, you can take your appeal to the Federal District Court if your health service or item is worth at least $1,760 (per 2021 regulations).
How Can I Avoid a Denial of Coverage from my Medicare Plan?
While you cannot always avoid billing or coding errors from your plan, you can help avoid getting a denial of coverage by taking the time to read your plan coverage details, and understand what is (and what is not) covered by your Medicare Advantage plan.
Talk with a local senior health plan advocate if you have questions about your Medicare plan coverage. They can help you better understand what is covered by your Medicare Advantage plan, so that you can plan ahead with medical services and items. They can also help make sure you are enrolled in the best plan for you based on your medical needs and budget. One of the best ways to avoid unexpected costs with denials of coverage is by choosing a Medicare Advantage plan that gives you the coverage you need.
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