How to Appeal a Medicare Claim, Step-By-Step

Appealing a Medicare claim involves several steps, especially if your claim is denied and you believe Medicare should have paid for it. Here's a step-by-step guide on how to appeal a Medicare claim:

Step 1: Review Your Medicare Summary Notice (MSN)

• The first step in the appeals process is to carefully review your MSN, which you receive every 3 months if you have Original Medicare. It shows all the services or supplies billed to Medicare on your behalf, what Medicare paid, and what you may owe the provider.

• Look for the denied service or item and check the reason for denial. This information is crucial for your appeal.
  

Step 2: File Your Appeal

• If you decide to appeal, you must do so within 120 days of the date you receive the MSN with the denied claim.

• On the MSN, there's a section for filing an appeal. Fill out the required information directly on the notice, or follow the instructions provided on the MSN to submit your appeal in writing. Make sure to include any supporting documentation that could help your case, such as a letter from your doctor explaining why the service or supply was necessary.
  

Step 3: Gather Documentation

• Collect any additional information that supports your appeal, such as medical records, doctor's letters, or other evidence that the service or item should have been covered.
  

Step 4: Submit the Appeal

• Send the appeal form or your written appeal with any supporting documentation to the address listed on the MSN. Keep copies of everything you send for your records.
  

Step 5: Review of Your Appeal

• Your appeal will go through a review process. The first level of appeal is handled by the company that handles bills for Medicare. They will review your appeal and make a decision.
  

Step 6: Further Appeals

• If your appeal is denied at the first level, you can proceed to the second level of appeal. There are five levels of appeal in total:

1. Redetermination by a Medicare contractor.

2. Reconsideration by a Qualified Independent Contractor (QIC).

3. Hearing before an Administrative Law Judge (ALJ) if the amount in controversy meets a minimum threshold.

4. Review by the Medicare Appeals Council.

5. Judicial Review in U.S. District Court if the amount in controversy meets a higher threshold.

Each level of appeal has specific deadlines and requirements for submitting your request. Be sure to follow these requirements closely and continue to gather and submit any additional evidence that supports your case.

Step 7: Receive a Decision

• After each level of appeal, you will receive a decision letter. If you disagree with the decision, you can usually appeal to the next level.
  

Throughout the appeals process, it's important to keep detailed records of all communications and to meet all deadlines. If you need help, give me a call. I have a back office of people that can help with challenges that come up.