How to file for Medicare appeals
This article was updated on: 07/25/2017
If you are a Medicare beneficiary, you have certain rights under the program, which include the right to file a grievance or request an appeal of a decision made about your coverage. Here’s what you need to know about the process.
What is the difference between Medicare appeals and grievances?
Some people use these terms interchangeably, but they mean two very different things, and the process for resolving them is quite different. Under Medicare:
- A grievance is any complaint or dispute, not involving a coverage determination, about the operations or behavior of any Medicare health plan, provider, or other individual involved in your care, whether or not you expect some remedial action. You can file a grievance simply to express your dissatisfaction with some aspect of your care or how you were treated.
- Medicare appeals are actions you take when you don’t agree with a coverage or payment decision Medicare or your Medicare health plan makes about your treatment. You may use the Medicare appeals process to try to reverse a decision made by Medicare or a Medicare-approved health plan. There are up to five levels to the appeals process.
What is the process for filing Medicare appeals?
The process differs slightly depending on whether you are enrolled in Original Medicare (Part A and Part B), or a Medicare Advantage plan, or if your dispute is over prescription drug coverage under a stand-alone Medicare Part D Prescription Drug plan.
Original Medicare appeals
Your first step is to appeal the decision to the company managing your Medicare claims. You can do this by completing this form, or by following the instructions on the back of your Medicare Summary Notice (MSN) that’s mailed to you every three months, or by writing a letter to the claims company at the address on the back of your MSN. You’ll generally get a decision within about 60 days; if you disagree with the redetermination, you have 180 days to file a request for reconsideration by a Qualified Independent Contractor (QIC).
To file this second level of appeal, which is reviewed by a QIC, complete and submit Medicare Reconsideration Request Form – 2nd Level of Appeal. You’ll receive a response, called a Reconsideration Notice, about 60 days after you file. You have 60 days from the date of the letter to proceed to Level 3, review before an administrative law judge
Medicare Advantage plans
You, your doctor, or a personal representative that you appoint can request an “organizational determination” from your Medicare Advantage plan if you disagree with a coverage decision. If you are not satisfied with the organizational determination, you have 60 days to file for a reconsideration from your plan, which is the first level of appeal. Depending on the type of decision you are appealing, the process may take from 72 hours to up to 60 days. If the plan decides against you, your appeal is automatically forwarded to Level 2, review by an Independent Review Entity (IRE).
The IRE has 72 hours to decide on a coverage decision for medical treatment your doctor believes is necessary, and up to 60 days for a payment request. If you disagree with the IRE’s decision, you have 60 days to escalate your appeal to Level 3, a hearing before an administrative law judge, described below.
Level 3: Medicare Appeals before an administrative law judge (ALJ)
You may request a hearing before an administrative law judge by submitting the form Request for an Administrative Law Judge Hearing or Review of Dismissal ; you’ll receive information about the date of your hearing, which may take place in person, over the phone, or by video conference. The ALJ has 90 days to issue a determination about your appeal. If you are still dissatisfied, you may escalate your Medicare appeals to Level 4, review by the Medicare Appeals Council.
Level 4: Review by the Medicare Appeals Council
To request review by the Medicare Appeals Council, follow the directions on the back of the decision you received from the ALJ, or complete and submit the form Request for Review of Administrative Law Judge Medicare Decision/Dismissal. The Medicare Appeals Council must send you a written decision within 90 days of receiving your request, and you have 60 days to escalate your appeal to Level 5, judicial review by a federal district court, if you disagree with your decision.
Level 5: Judicial review by a federal district court
To qualify for this level of Medicare appeals, your dispute must be at least $1,560 in 2017. Follow the directions on the back of your decision from the Medicare Appeals Council to initiate this process.
If you have trouble at any point during the appeals process, you may contact your State Health Insurance Assistance Program (SHIP) or Medicare Ombudsmen to get help (use this Medicare locator tool to find your local office). You can also call 1-800-MEDICARE 24 hours a day, 7 days a week.
Medicare Part D Prescription Drug Plans
If you believe your Medicare Prescription Drug Plan should cover a prescription medication that you need, and the plan doesn’t cover that drug, you can file an appeal to your plan. Either you or your doctor can file the appeal. For more information, see How to file an appeal for a prescription drug your plan doesn’t cover.
You may appeal a decision made by the private insurance company contracted with Medicare to administer your prescription drug plan by first requesting the plan issue a Coverage Determination. You or a health-care provider can call the plan, write them a letter, or submit the form Request for Medicare Prescription Drug Coverage Determination. Your plan has 72 hours to issue a decision. If you disagree with your coverage determination, you may request a redetermination from your plan. This may take anywhere from a few hours up to 7 days. If the plan decides against you, you may proceed to Level 2, review by an Independent Review Entity (IRE). An IRE review may take a few hours up to a maximum of 7 days to issue a decision. From here, if you are still unhappy with your decision, you proceed to Level 3, which is the same for enrollees in the Medicare program: A hearing before an administrative law judge.
If you need help with Medicare plans and appeals, I’m happy to assist you. You can request an email with personalized information or schedule a telephone call by clicking the appropriate button below. To see a list of plans in your area you may qualify for, click the “Compare Plans” button below. For immediate help, call me or another eHealth licensed insurance agent at 1-844-847-2660 (TTY users can call 711) Monday through Friday, 8AM to 8PM ET.
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