Appealing a Medicare Denial | What You Should Know

Imagine if all the money in your Medicare Set-Aside account has been spent and your medical bills are now being submitted to Medicare for payment. However, Medicare refuses to pay the bills and you now must begin appealing the denial. Read on and contact our team to learn more.

What are the steps to appealing your Medicare denial?

The Social Security Act establishes five levels to the Medicare appeals process: redetermination, reconsideration, Administrative Law Judge hearing, Medicare Appeals Council review and judicial review. Each level has different procedures depending on which Medicare Part has denied your claim.

Please note that you should consult with your attorney regarding your particular case as issues unique to your matter may impact the appeals process.

Level 1

Level 1 is the start of the claim appeals process and the appeals differ based on what part of Medicare you want to appeal. Parts A & B or “Original Medicare” includes hospital insurance (Part A) and supplementary medical insurance (Part B). Part C is the Medicare Advantage Plan program and Part D is the Medicare Prescription Drug program.

Your medical provider submits a bill to Medicare. Medicare contracts with private companies to process the bills, which determines if the services listed on the bill are covered or reimbursable by Medicare and they will inform you of its decision to pay or deny coverage of the entire bill or some portion of the bill.

Original Medicare (Part A & B)

If you disagree with the determination, the first level of an appeal for Original Medicare is called a redetermination. A redetermination is performed by the same contractor that processed the claim. However, the individual who reviews the appeal is not the same individual who processed the claim.

You can request an appeal within 120 days from the date you received notice from Medicare that they are not paying.

Medicare Advantage Plan (Part C)

If you are appealing a denial under your Medicare Advantage plan, it is called a request for reconsideration and you must make the request within 60 days of being notified of your plan’s initial decision not to pay for the claim and/or not allow the service. In most cases, your plan will notify you of its decision within 30 days if it involves a request for a service or 60 days if it involves a request for payment.

Now there is a wrinkle when it comes to appeals under a Medicare Advantage plan. Your Level 1 appeal for reconsideration will automatically be forwarded to Level 2 of the appeals process (discussed in more detail below) if your plan fails to respond to you within the required deadline or if the Level 1 appeal is not decided in your favor.

Medicare Prescription Drug Plan (Part D)

Now if you are appealing a denial under Medicare Prescription (Part D) plan, your Level 1 appeal is called a request for redetermination. You must file this appeal in writing within 60 days of the decision you are objecting to unless your plan accepts requests by telephone. You must check your plan to ensure you know the appropriate process for submitting a request for redetermination.

Once your plan has received your request, it has 7 days to notify you of its decision under a standard request. There is an expedited 72-hour process if your health will be seriously jeopardized by waiting for a standard decision. If your plan is unable to complete its decision within the required time, it is required to forward your appeal to Level 2.

Level 2

If you are not happy with Medicare’s decision on your Level 1 appeal or if your plan is backlogged you will need to move to Level 2 of the appeals process. In any event, just as in Level 1, the process for Level 2 appeals differs based on which part of Medicare you want to appeal.

Original Medicare (Parts A & B)

A Qualified Independent Contractor (QIC), retained by the Centers for Medicare & Medicaid Services (CMS), will conduct the Level 2 appeal, also known as a reconsideration. QICs have their own doctors and other health professionals to independently review and assess the medical necessity of the items and services under review.

You have to file for a Level 2 appeal within 180 days of receiving the written determination of your Level 1 appeal.

Level 2 appeals are conducted on the record and, in most cases, the QIC will send you its decision within 60 days of receiving your appeal. In addition to the determination, the notice should include detailed information about your right to appeal to Level 3 if you disagree with the QIC’s decision. If the QIC is unable to make its decision within the required time frame, they will inform you of your right to escalate your appeal to Level 3.

If your Level 2 appeal was unfavorable, you may file a Level 3 appeal with the Office of Medicare Hearings and Appeals (OHMA), as long as the amount in controversy (AIC) is $200.00 or greater.

Medicare Advantage Plan (Part C)

For a Level 2 appeal under your Medicare Advantage Plan, an Independent Review Entity (IRE) retained by CMS will conduct the appeal. This appeal, called a reconsidered determination, is conducted by the IRE’s own doctors and other health professionals. These professionals will independently review and assess the medical necessity of the items or services at issue.

After its review, the IRE will send you a notice which will detail your right to appeal to OHMA. You may appeal to Level 3 in writing within 60 days of your receipt of the IRE’s determination and if the AIC is $180.00 or more.

Medicare Prescription Drug Plan (Part D)

As with the Part C appeal, an IRE will also review your appeal under your Part D plan. In this instance, the IRE will take into consideration the views of your prescribing physician.

You must file your written Level 2 appeal within 60 days of receiving the notice of determination. In most cases, you will receive a notice of the IRE’s decision within 7 days after submitting your appeal. You may request a 72-hour expedited reconsideration if your life will be seriously jeopardized by waiting for a standard decision.

If you are not happy with the decision from the IRE, you must file your Level 3 appeal with OMHA within 60 days after receiving the decision and the AIC is $180.00 or more.

Level 3

If you are still in the fight at this point, all the Level 3 appeals go before OHMA. You can request a dismissal of the reconsideration or that the decision be reviewed by an OMHA adjudicator. Your request for a review will be assigned to an adjudicator, who will review it to ensure that all requirements have been met. If your appeal requires a hearing before an Administrative Law Judge (ALJ), the ALJ will schedule it and you will receive a Notice of Hearing. This gives you the opportunity to present your appeal to a new person, who will independently review the facts of your appeal before making a new and impartial decision in accordance with the applicable law.

In some instances, the adjudicator may decide a case on the record without a hearing if all the parties consent or if the documentary evidence supports a finding fully in your favor.

Generally, the time period for OMHA to issue a decision is 90 days. However, it is very likely based on the number of appeals, that the decision would not be completed within the 90-day period. At which point you could request that your case be escalated to Level 4.

Level 4

If you are not satisfied with your Level 3 decision or dismissal, you may request that the Medicare Appeals Council (Council) review the OMHA’s decision. The Council is part of the Department Appeals Board of the Department of Health and Human Services (HHS) and is independent of OMHA and its adjudicators. OMHA administers the nationwide ALJ hearing program for appeals arising under Medicare Parts A, B, C and D.

It is important to note that a party does not have the right to seek a Council review of the OMHA adjudicator’s determination. You must make a written request to obtain a Council review of the OMHA determination within 60 days after you have received the decision. The Council will assume that you received the OMHA decision five days after the date listed on the decision.

Typically, the timeframe for processing an OMHA review is 90 days, but this time frame can be extended for various reasons.

Level 5

If you disagree with the Council’s Level 4 decision and the amount in controversy is at least $1,760 (2022), you may file a civil action in your Federal District Court within 60 days of receiving the Council’s decision.

This is the last level of appeal. This is the higher power that may very well ultimately determine whether Medicare justly or unjustly denied your claim for coverage. Reaching this point will take months of not knowing if your treatment will ultimately be covered, so its vital that you, your attorney and your doctor do all you can to maximize the funds placed in your Medicare Set-Aside account and to make sure that those funds are properly spent. It is important that you consult with your attorney and your doctors at each level of the appeals process to ensure that all proper steps are taken and all medical issues are addressed.

Contact MSA Meds  

The best way to avoid the onerous and uncertain Medicare appeals process is to obtain CMS approval of the Medicare Set-Aside Allocation (MSA) and hire MSA Meds to professionally administer your MSA Account.   MSA Meds is here to help you protect your Medicare benefits! Contact MSA Meds today.