Medicare Appeals: How the Process Works and When to Use It

As a Medicare member, you have certain protected rights to ensure access to the healthcare you need.

One of those is the right to take action if you disagree with a Medicare coverage decision. This is called an appeal, and you can use it for concerns about each part of Medicare, including:

• Medicare Part A, which is hospital insurance
• Medicare Part B, which is medical insurance
• Medicare Part C, also called Medicare Advantage
• Medicare Part D, which is prescription drug coverage

You can use an appeal in a few different situations, such as denial of coverage for a test or service or if you’re charged a late fee you think is in error.

No matter the situation, you’ll need to prove your case to Medicare.

This means you’ll need to gather documented evidence from your doctor or other health providers that supports your reason for appealing. You’ll send this to Medicare along with your appeal form.

The appeals process has five levels. Each level is a different review process with a different timetable. You’ll need to request an appeal at each level.

If your appeal is successful at the first level, or if you agree with Medicare’s reasoning for denying your appeal, you can stop there. However, if your appeal was denied and you don’t agree with the reasoning, you can move to the next level.

There are two main times when you might file a Medicare appeal:

• when Medicare denies or ends your coverage for a service or item
• if you’ve been charged a penalty that has been added onto your monthly premiums

Coverage denial

You can file an appeal if Medicare has made a decision about your coverage that you think is in error. If your appeal is successful, the decision will be reversed or amended.

Times when you can appeal include situations when:

• You were denied prior authorization for an item, service, or prescription you think should be covered.
• You were denied coverage for an item, service, or prescription you’ve already received and think should be covered.
• You were charged a higher amount for a covered item, service, or prescription than you think is accurate.
• Your plan stopped paying for an item, service, or prescription you think is still necessary.
• You were charged a late enrollment penalty but had previous coverage.
• You were assessed an income-related monthly adjustment amount (IRMAA) that you don’t think is accurate.

There are a few reasons Medicare might deny your coverage, including:

• Your item, service, or prescription isn’t medically necessary.
• You don’t meet the eligibility requirements to have the item, service, or prescription covered.
• Medicare never covers the item, service, or prescription.

You won’t be able to get coverage, even with an appeal, if it’s something Medicare never covers.

However, if you think your item, service, or test is medically necessary or that you do meet the requirements, you can appeal. Your appeal will include the reason you think Medicare has made the wrong coverage decision.

Example 1

Let’s say you were receiving physical therapy and got a notice saying Medicare would no longer cover it. In this case, Medicare might have concluded that your physical therapy was no longer Medically necessary.

If you and your doctor believe you still need physical therapy, you can have your doctor verify medical necessity. You’d provide this document when you file the appeal.

Example 2

There are some tests, screenings, and preventive care that Medicare will cover at 100 percent when you meet certain requirements.

Let’s say you got your annual flu shot, which is typically fully covered. You later received a bill for the 20 percent Part B coinsurance amount. You could appeal the charge. You’d need to prove that you met the requirements for the vaccine to be 100 percent covered.

Penalties

You can also appeal decisions that affect your monthly premiums. This includes any late enrollment penalties you were charged when you signed up for Part B or Part D.

Medicare charges a late enrollment penalty if you don’t sign up for Part B or Part D when you’re first eligible or have similar adequate coverage in place.

If you had coverage from another source, like an employer health plan, but you were still charged a late penalty, you can appeal. You’ll need to prove you had coverage that was comparable to Medicare Part B or Part D to avoid these penalties.

Your premium may also be affected by an IRMAA amount you were assessed for Part B or Part D. IRMAAs are added surcharges you’ll pay on top of your Part B or Part D premium. They’re assigned based on your income and resources, as reported on your tax return from 2 years ago.

You can appeal an IRMAA if you think Medicare didn’t assess your income accurately.

You have 120 days from a Medicare denial or penalty to file an appeal.

Medicare will let you know in writing if your coverage has been denied or you’ve been assessed a penalty. The notice you’ll receive will let you know the steps you can take to file an appeal.

In a few cases, you’ll file what’s called a fast appeal. Fast appeals apply when you’re notified that Medicare will no longer cover care that’s:

• at a hospital
• at a skilled nursing facility
• at a rehabilitation facility
• in hospice
• by a home healthcare agency

You can appeal this notice if you think you’re being discharged too soon.

Your notice will tell you how to contact your state’s Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). The BFCC-QIO will notify the facility of your appeal and will review your case.

In the case of a hospital, the BFCC-QIO will have 72 hours to make its decision. A hospital can’t discharge you while your case is being reviewed by the BFCC-QIO.

In the case of nursing facilities or other inpatient care settings, you’ll receive a notice at least 2 days before your coverage ends. The BFCC-QIO will need to make its decision by the end of the business day before you’re due to be discharged.

For all other appeals, you’ll need to go through the standard appeals process, which we’ll go over next.

You’ve received an official notice

There are a few different notices you might receive from Medicare that would set off an appeal. Some common notices include:

• Advance Beneficiary Notice of Noncoverage (ABN). An ABN lets you know that an item, service, or prescription won’t be covered or will no longer be covered.
• Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN). An SNF ABN lets you know that Medicare will no longer be covering your stay in a skilled nursing facility. You’ll always get this notice at least 2 days before your coverage ends.
• Fee-for-Service Advance Beneficiary Notice. This notice lets you know that you’ll be charged for a service that you have received or will be receiving.
• Notice of Exclusion from Medicare Benefits. This notice informs you that a service isn’t covered by Medicare.
• Notice of Denial of Medical Coverage (Integrated Denial Notice). This notice tells you that all or part of a service won’t be covered by Medicare. This notice is used by Medicare Advantage plans.
• Hospital-Issued Notice of Noncoverage (HINN). An HINN lets you know that your hospital stay will no longer be covered by Medicare.
• Notice of Medicare Noncoverage. This lets you know that Medicare will no longer be covering your inpatient care from a skilled nursing facility, rehabilitation facility, hospice, or home care agency.
• Medicare summary notice. This shows you all your recent Medicare bills and claims. It will show you what Medicare paid and what you paid for any services you received.
• Initial IRMAA determination. An IRMAA determination lets you know the amount you’ll need to pay, based on your income or resources, in addition to your Part B and Part D monthly premium.

Initiating an appeal

You’ll need to appeal within 120 days of receiving notice for the noncovered service. The notice you receive will let you know what form you need to fill out and the address to send it to.

Generally, you’ll fill out a:

• Redetermination Request Form when you’re appealing a decision made about Medicare parts A or B
• Model Coverage Determination Request Form when you’re appealing a decision made about Medicare Part D
• plan-specific form if you’re appealing a decision made by your Medicare Advantage plan provider

No matter which form you fill out, you’ll need to include certain information about your claim, including:

• your name
• your Medicare number
• what noncovered item or service you’re appealing
• information about why you believe the service should be covered
• any evidence you have to support your claim

You can also send a letter to Medicare with this same information. Your doctor or other healthcare providers should be able to help you get supporting evidence. This might include things like:

• test results
• diagnoses
• certifications

Be sure to write your name and Medicare number on all of the information you send. You should receive a response within 60 days after sending your appeal request.

Levels of appeal

There are five levels of the Medicare appeal process.

The first level is called redetermination. This is where your initial appeal request will go. Redetermination is handled by the Medicare administrative contractor. They’ll review all the information you’ve sent and determine whether to cover your item, service, or prescription.

You can stop the process at level 1, or keep going if you still disagree with Medicare’s decision. The other levels are:

• Reconsideration. At level 2, a qualified independent contractor reviews your appeal. You’ll need to fill out a request for reconsideration and include a detailed description of the reason you disagree with the decision made at level 1. You’ll receive these results within 60 days.
• Filing an appeal with the administrative law judge (ALJ). At level 3, you’ll have the chance to present your case to a judge. You’ll need to fill out a request form detailing why you disagree with your level 2 decision. Your appeal will only be elevated to level 3 if it reaches a set dollar amount.
• Office of Medicare Hearings and Appeals review. The appeals board will review the ALJ decision made at level 3. You can request this by filling out a form and sending it to the board. If the board doesn’t hear your case within 90 days, you can move to level 5.
• Federal court (judicial). You’ll need to be disputing a set amount to have your appeal heard by a federal court. This is the final appeal level.

• You have the right to appeal decisions Medicare makes about your coverage.
• You’ll need to provide proof that your noncovered item, service, or test should be covered or that a penalty is incorrect.
• You can get a fast appeal if Medicare stops covering your stay in a hospital, skilled nursing facility, or other inpatient setting.
• You’ll hear a decision about your appeal within 60 days.