Filing Appeals for Medicare Insurance Claim Denials

By Nancy Bryce, Contributing Editor
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There is nothing more frustrating than having a Medicare Insurance claim denied. This is especially true when you are convinced that you are owed money.

In order for you to receive monies to which you are entitled, you must first be familiar with what is covered by your Medicare policy. Medicare only covers services that are medically necessary and charges considered reasonable.

Most Medicare recipients are enrolled in the Original Medicare Plan. This plan is a traditional fee for services plan. Part A of the Original Plan contains hospital insurance, and Part B provides supplementary medical insurance. You must understand your coverage under each part before you can file an appeal.

Managed Care Plans are also available from Medicare under the Medicare+Choice program. The Medicare+Choice program is a Medicare approved network of doctors, hospitals, and other health care providers that agree to provide care in return for set monthly payments from Medicare. There are several types of Medicare+Choice Managed Care Plans. Among these are, Health Maintenance Organizations (HMO’s), HMO’s with Point of Service Option (POS), Provider Sponsored Organizations (PSO’s), and Preferred Provider Organizations (PPO’s).

I found the publication, Medicare & You, issued by the Health Care Financing Administration (HCFA) particularly helpful in providing an overview of what is covered under the Original Medicare Plan as well as the new Managed Care Plans. You may obtain this publication through HCFA by calling

1-(800) MEDICARE or by logging onto their Internet web site at www.medicare.gov. Medicare & You, also contains helpful information about filing appeals for Medicare insurance claim denials.

Always remember that with Medicare you have the right to appeal decisions that deny or limit payment for medical care. In the sections below you will find appeal procedures for different Medicare claims.

  1. General Appeal Procedures Under the Original Medicare Plan
  2. Below is a list of procedures you should follow to file an appeal when your claim, filed under the Original Medicare Plan, has been partially or fully denied.

    _____ Review in its entirety, the Medicare Summary Notice (MSN) or other notice that was mailed to you.

    _____ Look closely at item 10, Non-Covered Charges, on your MSN to determine which charges were not covered.

    _____ Read item 15, Notes Section, for more information about your claim.

    _____ Review and complete item 18, Appeals Information, for tips on how to begin the appeal’s process.

    _____ Consult the back of the MSN, or other notice, for more information about your appeal rights.

  3. Appeal of Decisions by Intermediaries for Part A Claims
  4. In addition to following the above General Appeal Procedures Under the Original Medicare Plan (see Section A) continue with the appeal procedures below for Part A claims.

    _____ You may request an itemized statement from the provider of the service. You must receive it within 30 days of your request. If you have any questions, contact the Fiscal Intermediary. The name and phone number is on the notice.

    _____ File an appeal, by letter or by using HCFA Form 2649, within 60 days of receiving the notice of non-coverage. Based on your appeal, the health plan reviews its original decision to deny you coverage.

    _____ If after the review the plan upholds its denial, the appeal automatically goes to an intermediary reviewer that contracts with Medicare.

    _____ If the intermediary gives an unfavorable reconsideration, you will be given a statement of appeal rights and instructions for filing an appeal.

    _____ Decide whether you want to request a hearing before an Administrative Law Judge. At this point, you should involve a lawyer. You must request this hearing within 60 days of the disagreeable reconsideration, and the amount in question must be $100 or more.

    _____ If the Administrative Law Judge’s ruling is unfavorable, you may appeal to the Social Security Appeals Council.

    _____ If the Social Security Appeals Council upholds the denial of your claim, you may appeal to federal court when the amount at issues is $1000 or more.

  5. Appeal of Decisions by Carriers for Part B Claims
  6. In addition to following the above General Appeal Procedures Under the Original Medicare Plan (see Section A), continue with the following actions for Part B claims.

    _____ Request reconsideration of the carrier’s decision within six months of receiving the decision.

    _____ The carrier will send you notice of the results of the review.

    _____ If the notice of results is disagreeable, you may request a hearing before the carrier’s hearing officer within 60 days after the notice. The carrier officer will review documents and make a recommendation.

    _____ If you disagree with the carrier officer’s decision, you have 60 days in which to request a hearing before an Administrative Law Judge if the amount in dispute is at least $500.

    _____ If the appeal is still unfavorable, you may request a review by the Social Security Departmental Review Board within 60 days. The Review Board may decide not to review your case.

    _____ You may follow through with a federal court hearing if the amount in dispute is at least $1000.

  7. Appeal of Early Hospital Discharge
  8. _____ If you believe you are being discharged from a hospital too soon, you may request immediate review by the Peer Review Organization (PRO) in your state. A PRO is a group of practicing doctors and other health care professionals paid by the federal government to decide whether care given to Medicare recipients is reasonable and meets generally accepted standards of quality by the medical profession.

    _____ You can stay in the hospital without being charged and you will not be discharged before the PRO makes a decision.

  9. Appealing Decisions Made by Skilled Nursing Facilities
  10. _____ A denial of Medicare coverage by a skilled nursing (SNF) does not represent an official denial of Medicare coverage. Therefore, if you disagree, you can insist the SNF file a "demand billing" with its Medicare intermediary.

    _____ Once the demand bill is submitted the Medicare intermediary will make an official coverage determination.

    ____ If you disagree with the intermediary’s decision, follow the actions outlined in section B above entitled, Appeal of Decisions by Intermediaries for Part A Claims.

  11. Appeal Procedures for Managed Care Plans

Under Managed Care Plans, you should take the following actions to file an appeal.

_____ Read your policy before you file an appeal to ensure you understand your coverage. This sounds easy, but the information provided by Managed Care companies can be confusing. Therefore, if you are ever unsure, contact your insurance company directly.

_____ Find out why the claim was rejected. Check the message found on the Medicare Summary Notice (MSN) or the notice you received. If you are confused and feel your claim should have been paid, file an appeal.

_____ Follow the appeal procedures outlined by your health plan. Refer to your policy or contact your health plan for details about your rights and how to file a Medicare appeal. The appeal procedures for Medicare claims should be essentially the same for each plan and are as follows:

_____ You are entitled to reconsideration. You must request reconsideration in writing within 60 days of the insurance company’s determination.

_____ If the health plan partly or completely upholds its denial, the case will be sent to the Health Care Financing Administration’s (HCFA’s) contractor for processing reconsiderations within 60 days.

_____ If the HCFA contractor upholds its denial, you may request an Administrative Law Judge hearing if the amount in question is at least $100.

_____ You may be eligible for an expedited decision (within 72 hours), if your health or ability to function could be seriously harmed by following the appeal schedule.

If you require more information about any of the appeal procedures discussed in this article, call the Medicare intermediary or carrier in your state or call Social Security. Before you file an appeal, it is also prudent to speak with a representative of your State’s Insurance Counseling and Assistance Program (ICA). Your local ICA provides free insurance counseling.

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