If you’re covered by Medicare, in the course of seeking treatment there’s a chance that Medicare may deny coverage for a procedure. There are two instances in which this can occur. It may occur if Medicare determines that the treatment or procedure is experimental or medically unnecessary. It may also occur after treatment when you receive your bill along with a notice that Medicare will not be paying for it. In either case, there are options available to you through the Medicare appeals process. While this process can be lengthy, the good news is that it has a good chance of working out in your favor. Appeals for Part A coverage have an 80 percent success rate, and Part B appeals have a 92 percent success rate. Here’s how to go about making an appeal.
The Medicare Appeals Process
First, when you receive your Medicare Summary Notice, write “Please Review” on it, with your signature on the back and send it to the address given for reviews. Ask your doctor for a letter of support to backup his or her decision that the treatment is necessary, and include a letter of your own as well. Make photocopies of all of these documents for your own records. Remember that you only have 120 days from the date on the notice to do so. Send the letter with delivery confirmation to ensure it reaches the appeals office.
The Medicare Advantage Appeals Process
If you have Medicare Advantage (Part C) the appeals process is slightly different, because you’re dealing with a private insurer. You have only 60 days as opposed to 120 to file an appeal. If your appeal is denied, you can appeal to an Independent Review Entity. From there, if your appeal continues to be denied, you can continue the process by appealing to an Administrative Law Judge, and the Medicare Appeals Council. If your appeal is still denied, your last option (if the claim is large enough) is to seek the review of a court.
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Tags: Medicare appeals