How do I appeal a Medicare denial?

What Medicare decisions can I appeal?

You can appeal when Original Medicare, your Medicare Advantage or other Medicare health plan, or your Medicare drug plan makes a coverage or payment decision you disagree with. You can file an appeal if Medicare or your plan:

• Refuses to cover a health care service, supply, item or drug you think Medicare should cover.
• Refuses to pay for a service, supply, item or drug you already got.
• Refuses to change the amount you must pay for a service, supply, item or drug.
• Stops providing or paying for all or part of a service, supply, item or drug you think you still need.
• Labels you "at-risk" under a drug management program that limits your coverage of drugs like opioids and benzodiazepines.

How do I appeal in Original Medicare?

Start with your Medicare Summary Notice (MSN), the statement people with Original Medicare get for Part A and Part B services; its last page gives step-by-step directions. You must file by the date in the MSN. If you miss it, you can still get a decision if you show good cause, such as a disability, illness or accident that kept you from filing on time. To file a level 1 appeal (redetermination), either send a Redetermination Request Form (Form CMS-20027) to the Medicare Administrative Contractor (MAC), or:

• Circle the item or service you disagree with on a copy of your MSN.
• Explain in writing, on the MSN or a separate page, why you disagree.
• Include your name, phone number and Medicare Number, plus anything that helps your case, like a doctor's note.
• Mail it to the address on the last page of your MSN, and keep a copy for your records.

What happens if Original Medicare still says no?

The MAC generally decides within 60 days. If Medicare will cover the item, it shows on your next MSN; if not, you get a letter called a Medicare Redetermination Notice. You then have 180 days to ask for a level 2 appeal, a reconsideration by a Qualified Independent Contractor (QIC) that didn't take part in the first decision, which decides within 60 days.

After that, levels 3 to 5 follow the same steps in Original Medicare, Medicare Advantage plans and Medicare drug plans. You have 60 days to ask for level 3, a decision by the Office of Medicare Hearings and Appeals (OMHA), where an Administrative Law Judge usually holds a hearing by phone or video-teleconference, or, if you ask, an Administrative Law Judge or attorney adjudicator decides from your appeal record without a hearing. Then you have 60 days to ask for level 4, a review by the Medicare Appeals Council, and 60 days after that for level 5, judicial review in federal district court. Levels 3 and 5 apply only when the amount in dispute meets a minimum dollar amount Medicare sets each year; for level 5 you may be able to combine claims to reach it.

How do I appeal a Medicare Advantage plan decision?

In a Medicare Advantage plan, a coverage decision is called an organization determination, and you, your representative or your provider can ask the plan for one before you get a service. If the plan says no, the level 1 appeal is a reconsideration by the plan: you, your representative or your doctor must file within 65 days from the date on the plan's denial notice, following the directions in that notice. If you file late, you must give a reason.

The plan has 30 days to decide an appeal for a service you haven't gotten, 60 days for a payment appeal and 7 days for a Part B drug appeal, though it can sometimes take up to 14 more days and must tell you in writing. Ask for a fast appeal if waiting could seriously harm your life, health or ability to regain maximum function: the plan must then decide within 72 hours. If the plan still denies all or part of your request, it automatically sends your case to an Independent Review Entity for level 2. See how prior authorization works in Medicare Advantage.

How do I appeal a Medicare drug plan decision?

In a Medicare drug plan, the plan's first decision about whether it covers a drug, whether you met its rules, or what you pay is called a coverage determination. You or your prescriber can ask for one, or for an exception (for example, to cover a drug that isn't on the plan's formulary or to waive a rule like prior authorization); an exception needs a statement from your prescriber explaining the medical reason.

If the plan says no, you, your representative or your prescriber can ask for a level 1 appeal, called a redetermination, within 65 days from the date on the denial notice. The plan has 7 days to decide a standard drug appeal, 14 days for a payment appeal and 72 hours for a fast appeal. If the plan upholds its denial, you have 60 days to ask for a level 2 reconsideration by a Part D Independent Review Entity, and the later levels follow the same steps as Original Medicare.

What if my hospital or nursing care is ending too soon?

You can ask for a fast appeal if you think covered services from a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility or hospice are ending too soon. An independent reviewer, the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), decides whether your services should continue.

In a hospital, you should get a notice called "An Important Message from Medicare about Your Rights"; follow its directions no later than the day you're scheduled to be discharged, and you can stay while you wait for the decision without paying for the stay beyond your usual coinsurance or deductibles. In other settings, you should get a "Notice of Medicare Non-Coverage" at least 2 days before services end; ask by noon the day before the end date on that notice. If a hospital changes your status from inpatient to outpatient getting observation services, you can also ask for a fast appeal while you're still there. See how Medicare treats observation stays.