There are times when Medicare denies Medicare beneficiaries coverage for a service, test, or item. And as a Medicare beneficiary, you have the right to formally disagree with the Medicare decision and have them change it. This process is known as “Medicare Appeal.” Medicare permits you to file for an appeal form along with the reason why you oppose the decision. Your appeal will be reviewed, and a new decision will be made. Now let’s take a closer look into what a Medicare appeal is.
What Is a Medicare Appeal?
As a Medicare beneficiary, you have protected rights to make sure you have access to the health care you deserve. And one of these protected rights is to take formal action when you disagree with a Medicare coverage decision. You can use this appeal for concerns about each part of Medicare – Medicare Part A, B, C, and D.
Medicare appeals can be used in a couple of different situations, such as the denial of coverage for a service or test or if you are charged a late fee you feel is not right. With the help of your medical professionals, you will need to document and gather the evidence that supports your reason for appealing the decision.
Process for Filing a Medicare Appeal?
A Medicare member has 120 days from when they receive the notification from Medicare that they will be denied or penalized to file an appeal. Whenever your coverage has been denied, or you have been fined, Medicare will inform you in writing. This notice will inform you of the steps you can take to file an appeal for the decision. In certain cases, you can file what is called a “Fast Appeal.” This appeal applies when you receive a notification that Medicare will no longer provide coverage for care in the hospital, skilled nursing facility, hospice, rehabilitation facility, or home healthcare agency.
If you feel you are discharged too soon, you can appeal the notice. The notice you receive will also inform you how to contact the Medicare Quality Improvement Organization. This organization will notify the center of your Medicare appeal, and your case will be reviewed.
Levels of Medicare Appeal
You have several changes to resolve your conflict with Medicare. The Medicare appeal process for Original Medicare has five levels. The five levels of the appeal process are as follows:
- Level 1: Your appeal is redetermined by your Medicare administrative contractor, Medicare carrier, or fiscal intermediary.
- Level 2: Redetermination by a qualified independent body.
- Level 3: The Office of Medicare Hearings and Appeals has an administrative law judge that will review your appeal.
- Level 4: Your appeal is reviewed by the Medicare Appeals Council.
- Level 5: The federal district court review your appeal
If you need more information about the Medicare appeal process or need help to file an appeal, contact Cornerstone Senior Advisors. Our Medicare professionals can help you.