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About Medicare Appeals

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There are several reasons why you might choose to file a Medicare appeal, but it generally boils down to a disagreement with a coverage or a payment decision. Whether you have Original Medicare (Part A and Part B), a private Medicare Advantage plan, or a Medicare prescription drug plan, you have the right to file an appeal in some situations.

If Medicare or your Medicare plan doesn’t cover a particular health care service, prescription drug, or piece of equipment that you feel it should, then you’re entitled to submit an appeal. Additionally, you can file an appeal for payment of a service, drug, or item that you already received, or request to change the amount you have to pay for any of those things. Finally, you have the right to appeal if Medicare or your Medicare plan stops providing or paying for all or part of any service, drug, or equipment you believe you still need.

Medicare beneficiaries enrolled in a Medicare Medical Savings Account (MSA) plan have the right to file an appeal if they believe that a service or item should count toward their deductible.

During an appeal

Whether you receive your coverage through Original Medicare or belong to a private Medicare Advantage or prescription drug plan, you can receive information on coverage details and costs ahead of your coverage start date so that you understand what’s covered by Medicare or your Medicare plan, and what your portion of costs will be.

If you choose to file an appeal, understand that you can seek additional help from your doctor and/or health-care provider or equipment supplier. Ask if he or she is willing to make a statement that supports your case.

The appeals process for Original Medicare, Part A and Part B, has five levels listed below (and explained in greater detail in this article). The five levels of the appeals process are as follows:

Level 1: Redetermination by a Medicare carrier, fiscal intermediary, or Medicare administrative contractor

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

Level 3: Hearing by an Administrative Law Judge (ALJ) in the Office of Medicare Hearings and Appeals

Level 4: Review by the Medicare Appeals Council

Level 5: Judicial review in federal district court

You might disagree with the decision(s) reached at the end of any level. If this happens, you can generally move onto the next level of appeal. If you’d like to do this, you’ll find instructions for doing so included in the current level decision letter.

If you belong to a private Medicare plan, you can contact your insurance company directly to find out the next steps when it comes to your Medicare appeal. Medicare.gov has more information on appeals.

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