Question: Medicare denied payment for services I recently had and indicated I could appeal their decision. How do I start this process?
ANSWER: Denial of payment for services can occur for many reasons. Before starting the appeal process it would be wise to talk with provider’s office to see if the problem is due to something as simple as a billing error. If so, ask that the billing be corrected and the bill resubmitted to Medicare for payment.
However, if that is not the cause of the denial then you should start the appeal process. Approximately half of all appeals are successful so it is worth doing.
If your health care coverage is from original Medicare then your appeal process is made directly to Medicare. Medicare’s process consists of five levels: request for redetermination, request for reconsideration, hearing before an administrative judge, submitting a claim to appeals counsel review and judicial review in U. S. District Court.
Your request for redetermination starts with a review of your Medicare Summary Notice (MSN). The MSN lists all of the services, supplies and equipment billed to Medicare for a specific period of time for your care.
Each entry will show you who provided the service, the amount billed, the amount Medicare approved, the amount Medicare paid and the amount you may be responsible for. This entry will be followed by a letter or letters. These letters will appear again at the end of the MSN with an explanation about the outcome of that claim.
After receiving a denial of a claim you have 120 days to request a redetermination by a Medicare contractor who will review your claim and issue a response. You can request a redetermination by using your MSN. Circle the items you are disputing and provide an explanation of why you believe the decision should be reversed. Attach any supporting documents you have explaining your reason for the request.
Keep a copy of the MSN and any supporting documents for your file and send the copy to the address on the MSN.
You should hear back within 60 days. If your request is denied again you can request a reconsideration from a different claims reviewer. The instructions for requesting a reconsideration will be included on the returned form.
Appeals at the higher levels are more complicated and involve the amount of claim in dispute and a question of law. If you take an appeal to this level I recommend you have representation to assist you with the process.
If your denial is with a Senior Advantage Plan the process is slightly different. You must file your appeal within 60 days of the denial and you must direct your appeal directly to the plan you are enrolled in and follow the plan’s instructions.
If your denial is with your Part D Prescription Drug Plan you have 60 days from the date of denial notice and you must deal directly with the drug plan in which you are enrolled.
Part D Plans also have a fast-track appeal of 72 hours if you haven’t received your medication and waiting would jeopardize your health. Otherwise, the plan must notify you of its decision within 7 days.
For more information on the Medicare appeal process visit Medicare.gov or call (800) 633-4227 and request a copy of Medicare Appeals publication No. 11525. You can also read this information on line at medicare.gov/pubs/pdf/11525.pdf.
Hope this gives you what you need to know to start your appeal process.
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HAPPENINGS:
TUESDAY – September 10 – 4:05 pm – “Take Me Out to the Ballgame” – Dodgers vs. the Baltimore Orioles – at the Goebel Adult Community Center – enjoy Dodger Dogs, popcorn, peanuts and more. Tickets are $7.00 and doors open at 3:00 pm.
WEDNESDAY – September 11 – 12:30 to 2:30 pm – Support Group – Ventura Parkinson’s Disease – will host “The Michael J. Fox Foundation for Parkinson’s” – at Ventura City Hall’s Community meeting room #202, 501 Poli Street in Ventura. For more information call Patty at (805) 766-6070.
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Betty Berry is a senior advocate for Senior Concerns. The advocates are located at the Goebel Adult Community Center, 1385 E. Janss Road, Thousand Oaks, CA 91362 or call (805) 495-6250 or e-mail bberry@seniorconcerns.org (please include your telephone number.) You are invited to submit questions on senior issues.
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