An appeal is a formal request for review of a decision made by Original Medicare or your Medicare Advantage or Part D plan. If you were denied coverage or authorization for a health service or item, you may appeal the decision. Let’s learn about how you can do this.
Keep the following in mind as you prepare to start your appeal:
- Make sure you read all the letters and notices sent by Medicare or your plan. Call Medicare or your private plan to learn why they’re denying your coverage, if the reason wasn’t given or if you don’t understand it. This will help you address the reason for denial in your appeal letter.
- You can strengthen your appeal by including a letter of support from your doctor that explains why you need the service or item.
- There is more than one level of appeal, and you have the right to continue appealing if you are not successful at the first level.
- Make sure to file each appeal in a timely manner, or your appeal may not be considered. If there is a reason you can’t submit your appeal within the timeframe, you may be eligible for an extension.
- Keep in mind that an appeal is different from a grievance, which is a formal complaint that you file with your plan.
- Your State Health Insurance Assistance Program (SHIP) can help guide you through the appeals process. Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to find your local SHIP.
If you have Original Medicare, you can see a denial on your Medicare Summary Notice (MSN).
The MSN is a summary of health care services and items you have received during the previous six months. The MSN is not a bill. MSNs contain information about charges billed to Medicare, the amount that Medicare paid, and the amount you are responsible for. If your MSN says that Medicare did not pay for a service, and you think it should, call your doctor before appealing to make sure that there was not a billing error. Then, start your appeal by following the appeal instructions listed on your MSN. Next, send your appeal to the Medicare Administrative Contractor, or MAC, within 120 days of the date on your MSN. The MAC’s name and address are listed on your MSN. The MAC should make a decision within 60 days. If your appeal is successful, your service or item will be covered. If your appeal is denied, you can move on to the next level by following the instructions on the MAC denial notice.
If you have a Medicare Advantage plan, the process depends on if you have already received the care or not.
If your plan denies coverage or authorization for a health service or item before you receive it, you can appeal to ask the plan to reconsider its decision. Before you start your appeal, you will need to get an official written decision from your plan, called a Notice of Denial of Medical Coverage. You can start your appeal by following the instructions on the Notice of Denial of Medical Coverage and filing your appeal within 60 days of the date on this notice. You will need to send a letter to your plan explaining why you need the service or item. Your plan should make a decision within 30 days.
This process looks a little different if your plan denies coverage for a service or item that you have already received. You should receive a written notice from your plan stating that it is not covering your health service or item. This can either be an Explanation of Benefits, called an EOB, or a Notice of Denial of Payment. This is not a bill. Start your appeal by following the instructions on the notice you received from your plan, and file the appeal within 60 days of the date on the notice. Your plan should make a decision within 60 days. If your appeal is successful, your service or item will be covered. If your appeal is denied, you can move on to further levels of appeal by following instructions on the denial notice.
This month’s Medicare fraud reminder:
It’s important to stay updated about Medicare fraud because the schemes are always changing. Recently, skin substitutes have become the center of recent Medicare fraud scheme. Skin substitutes are a type of special wound care for wounds that do not heal. They act as a protective cover and support new tissue growth. Skin substitutes can be made from biological materials (like donated human or animal tissue) or synthetic materials. They are typically used with chronic, non-healing wounds that have not responded well to other treatments.
Medicare costs for skin substitutes recently skyrocketed, surpassing $10 billion annually by the end of 2024. Data show that skin substitutes are vulnerable to fraud schemes. It’s important to look out for red flags related to skin substitutes, so that you can spot and report bad actors.
Beware of these red flags:
- You see claims on your Medicare statements for skin substitutes that you did not receive, request, or need.
- You were provided or billed for medically unnecessary treatments or excessive amounts of product.
- Your loved one in hospice care is offered complicated wound care from a sales representative. Patients nearing the end of their lives can be vulnerable to skin substitute fraud.
Skin substitutes may appear on your Medicare statements using the following billing codes:
- Skin substitute products: Q4100-Q4397
- Application of skin substitutes: 15271-15278
If you think you have experienced potential Medicare fraud, errors, or abuse contact your local Senior Medicare Patrol using the online SMP Locator or by calling 877-808-2468.
Still have questions?
Your SHIP is here for you! You can contact your SHIP for any Medicare-related questions or concerns you have. SHIP counselors are government funded to provide trusted, unbiased Medicare counseling at no cost to you. (Depending on your state, your SHIP may go by another name.) Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted) to find your local SHIP.
If you think you have experienced potential Medicare fraud, errors, or abuse contact your local Senior Medicare Patrol using the online SMP Locator or by calling 877-808-2468.