Medicare Appeals Process Explained

No matter what Medicare Plan you are on, you have the right to appeal any decision about your Medicare coverage.  If Medicare does not pay for an item or service that you feel you are entitled to, you can appeal that decision.

This is not necessarily an easy process; however, there are ways it can be done.  For instance, there are various appeal forms depending upon what plan you are on.  They are available by downloading from the internet or calling the Medicare program you are enrolled in.  The information should be on your Medicare card and your monthly statement.

If you file an appeal, Medicare has a limited amount of time to respond to you and at least let you know that they are looking into the matter.  Often, you will hear from them in 7 to 10 days. 

If you are not satisfied with any decisions regarding your appeal, you will be advised as to the next level you can go to.  It is similar to taking a matter to civil court, then superior court then district court then the Supreme Court.  With Medicare, hopefully you won’t have to go all the way to court. 

There are five levels to an appeal.  First, redetermination by a Medicare carrier, intermediary, or Medicare Administrative Contractor.  Second is review by a Qualified Independent Contractor.  Third is hearing by an Administrative Law Judge in the Office of Medicare Hearings and Appeals.  Fourth is review by Medicare Appeals Council, and Fifth is Judicial Review by Federal District Court.  Most cases are settled long before they get to step number five.

No matter what your question, grievance or appeal is, try to start by getting information directly from your Medicare provider.  This may take some work, research and time, but it can save a lot of time and effort in the long run if you do not have to go through the entire appeals process. 

For questions or information, call Medicare at 1-800-MEDICARE.

Filed under: General-Medicare

Tags: appeal, disability, General-Medicare, medicaid, part a, part b, social security