Can You Appeal Against a Medicare Decision?

Medicare approves that vast majority of claims it receives. When you see the doctor, you can be confident that Medicare will pay its share of the bill. Sometimes, however, you get an unexpected bill for a service you believe should be covered. When that happens, you have the option to file an appeal. 

Original Medicare Appeal

Medicare denies services for different reasons. The service might not be covered by Medicare Part A or Medicare Part B, for example, or Medicare believes the service isn’t medically necessary.  You can file a Medicare appeal if you believe Medicare denied a service that should be covered by Medicare. 

Medicare mails a Medicare Summary Notice to enrollees every three months. The MSN lists all the services and supplies billed to Medicare on your behalf and how they were covered by Medicare. You should always carefully review your MSN as soon as you receive it. 

If Medicare denies a service you think it should cover, your first step is to contact the provider and ask them to verify the information they submitted to Medicare. In many cases, your doctor’s billing department can correct the claim and solve the problem without any additional effort on your part. 

If your provider confirms they billed Medicare correctly for a denied service, your next step is to file a formal appeal. You can find information about the appeals process on the last page of your MSN. 

You will need to write a letter explaining why you believe Medicare should have paid the claim. It’s a good idea to ask your provider for a copy of any notes and records related to the denied service. Your provider may also write a note on your behalf. 

Write your Medicare ID number at the top of every document you plan to send to Medicare and make copies of everything for your records. Send your appeal request to the address listed on your MSN. Once Medicare receives your appeal request, it has 60 days to make a determination. If Medicare reverses the denial and pays the claim, you don’t need to do anything else. 

If Medicare denies your appeal, however, you have the option to escalate your appeal to the next level. You can find the information for escalating your request on the decision notice you receive from Medicare. 

Keep in mind, there is a time limit for submitting an appeal to Medicare. Generally, Medicare must receive your request within 120 days from the date of your MSN. 

If you have Medicare Advantage, the above appeal steps don’t apply. Instead, you will follow the appeal instructions provided in the denial notice sent by your plan. 

Part D Appeal

Appealing a Part D decision is a little different than filing an Original Medicare appeal. If your Part D plan denies a claim for medication because it’s not on the plan’s formulary, you can file an expedited formulary exception appeal. This is the most common type of appeal with Part D plans. 

You will file your appeal with your Part D plan provider, not Medicare. You can file a formulary exception before you fill a prescription or after you pay for it. A formulary exception is simply a request for your plan to cover a drug that isn’t included in the formulary or to lift a restriction placed on the medication. 

You or your provider can file a formulary exception appeal. Whoever files the appeal must send a letter and any other relevant documentation that supports your need for the medication. Your plan has 72 hours to respond to a formulary exception appeal, or 24 hours if you request an expedited appeal. 

If the plan approves your request, you don’t need to do anything else. The plan will pay for the medication or reimburse you if you already paid for it yourself. If it denies your appeal, however, you have the option to escalate to an Independent Review Entity within 60 days of the formulary exception denial. You can find instructions for escalating your appeal on your Notice of Denial. 

Summary

Receiving a bill that you’re not expecting is frustrating. Fortunately, you’re not without options. Just remember to read your MSN carefully when you receive it and follow the appeals process carefully so you have the best chance of winning your appeal. If you have any trouble along the way, contact your provider, your plan, or your Medicare broker for help.

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