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The Medicare Appeal Process

All patients that receive Medicare benefits have the right to appeal the denial of any claim. But appealing a decision from Medicare may not be as simple as you think. It is necessary to understand when you should file an appeal on your claim decision, and how that appeal should be filed in order to complete the process successfully.

When to File an Appeal

There can be many reasons you would want to appeal a decision. Obviously, if a claim has been denied and you feel that the item or service should be covered by your plan, you will want to appeal. Additionally, perhaps you have been denied coverage for something that was covered previously. You will want to appeal this to determine why the item is no longer covered.

Another instance when you may want to appeal a Medicare coverage decision is when a service you receive on a regular basis is denied for coverage. If you feel that you still should be receiving this treatment, you should appeal the decision and try to get the coverage reinstated and learn about reading fine print of Medicare notices to gain a thorough understanding. Finally, you will want to appeal any decision wherein you feel that the portion you are being made to pay is incorrect.

How to File an Appeal

The appeal process differs depending on which type of Medicare plan you are on. If your plan is the "Medicare Prescription Drug Plan", you will want to familiarize yourself with covered medicines prior to attempting to get a prescription filled. This is called a "coverage determination", and you can obtain it by contacting Medicare directly.

This determination will outline for you if Medicare has deemed whether or not a drug is covered. It will also tell you if you are eligible to be treated with the drug in question.

If your health care provider believes you need to be on a medication that is not covered, all is not lost. You (or your provider) can request an exception from Medicare. Additionally, if there are restrictions on that particular medication, a waiver can be requested. If good cause can be show for either, an exception can be granted.

If you are on the "Original Medicare Plan", there are two ways to appeal a decision. The appeals process for the "Original Medicare Plan" is detailed on the back of your quarterly Medicare Summary Notice. Simply follow these instructions in order to file.

Alternatively, there is a form on the Medicare website called the "Redetermination Request Form". This form can be completed and returned to the address listed on the Medicare Summary Notice in order to initiate the appeals process.

The appeals process for the "Original Medicare Plan" generally takes thirty to sixty days to complete. On rare occasions you may be contacted for more information, but usually everything that they need is already requested on the two forms mentioned previously. If more information is requested, be sure to return it to the review board promptly so as to ensure the timely consideration of your appeal. The notification of the decision regarding your appeal will come either in your quarterly Medicare Summary Notice, or in a separate letter.

Finally, if you have a "Medicare Health Plan", the appeals process may be quite different. A "Medicare Health Plan" is one that is managed by a private insurance company such as Humana or Aetna. Because these plans are managed privately, the appeals process is determined by each individual provider. There should be a section regarding how to file in the plan information you receive when you sign up. However, if you aren't sure, contact them to learn the Medicare appeal process for that company.

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