What You Need to Know About Medicare: Medicare Appeals

Ideally, Medicare will always pay what it is supposed to when it is supposed to, but this is the real world and unfortunately Medicare doesn’t always work the way it is supposed to. When Medicare doesn’t work the way it should, you can file an appeal.  

Medicare Advantage Appeals 

While filing an appeal with Medicare is relatively straight forward, filing an appeal with Medicare Advantage is dependent on the insurance provider and is one of the major reasons to ensure that you have chosen the right Medicare Advantage provider (if that is the plan you choose).  If you have a Medicare Advantage plan, you will need to contact your insurance provider to inquire about instructions for its appeals process. If you think the Medicare Advantage program’s refusal is jeopardizing your health, ask for a “fast decision.” This request legally compels the provider to respond to your request within 72 hours.41    

Original Medicare Appeals

If you have original Medicare, you will need to do the following to file an appeal: 

• You must file the appeal within 120 days of the date you get the MSN (Medicare Summary Notice). Make sure to follow all the appeal instructions on the back of the MSN.42  
• Circle the items you disagree with on your MSN and write an explanation on the MSN (or another sheet of paper) stating why you disagree. Your MSN is the statement you get every 3 months that lists all the services billed to Medicare and tells you if Medicare paid for the services. 
• Sign, write your address, telephone number, and provide your Medicare number on the MSN. Keep a copy for your records. 
• Send the MSN or a copy to the Medicare contractor’s address listed on the MSN, along with any additional information you have about the appeal. 
• Expect to hear back within about 60 days from the day the Medicare contractor receives your appeal.43  

Medicare Part D Appeals

Much like Medicare Advantage appeals, the process of appealing to Medicare Part D varies by insurance provider and you should contact your provider for specific instructions. In general, the steps you will need to take are as follows: 

• Talk to your doctor about the situation, and make sure that the uncovered drug can’t be substituted for a drug that is covered by your plan. 
• If you can’t substitute drugs, ask your doctor to write an explanation as to why the drug is necessary and cannot be substituted. Then submit your request to the Medicare Part D plan provider. The provider will generally provide you with a coverage decision within three days, although you can request a faster decision if it is medically necessary. 
• If your insurance provider denies your request, you can file a formal appeal. Depending on your plan, you will usually have to file a formal appeal within 60 days of the original coverage determination. If you need help filing a formal appeal, your state’s Health Insurance Assistance Program can help you through the process. The plan must respond to a formal appeal within a week.
• If your formal appeal is denied, you can appeal again, but this time your appeal goes to an independent organization that works for Medicare. Your insurance provider can give you instructions on how to file a second formal appeal.44

Where to Go for Extra Information

• The Medicare Handbook https://www.medicare.gov/pubs/pdf/10050-Medicare-and-You.pdf 
• New Enrollee Checklist https://www.medicare.gov/sign-up-change-plans/get-started-with-medicare/year-1-your-medicare-checklist
• The State Health Insurance Assistance Program (SHIP) is funded through grants to help provide information, counseling, and assistance to Medicare beneficiaries and their families with questions related to Medicare, Medigap, Medicare Advantage, Medicare Savings programs, Medicaid, Long Term Care Insurance, and other health insurance issues.
• Your State Department of Insurance can be a good source of information with regard to Medicare policies available in your area.
• Medicare provides informational resources online at www.Medicare.gov or over the phone at (800) 633-4227. 
• National PACE Association www.npaonline.org.
• The Social Security Administration provides information on extra help at www.socialsecurity.gov/extrahelp or by phone at (800) 772-1213.

Sources: 

• “Medicare Appeals.” www.medicare.gov, https://www.medicare.gov/Pubs/pdf/11525-Medicare-Appeals.pdf.
• “Medicare Appeals.” www.medicare.gov, https://www.medicare.gov/Pubs/pdf/11525-Medicare-Appeals.pdf.
• “Medicare Appeals.” www.medicare.gov, https://www.medicare.gov/Pubs/pdf/11525-Medicare-Appeals.pdf.
• “Appeals in a Medicare Prescription Drug Plan.” www.medicare.gov, https://www.medicare.gov/claims-appeals/how-do-i-file-an-appeal.