How to Appeal a Medicare Denial Decision

According to the 2008 American Health Association National Health Insurer Report Card, Medicare denied just under 7 percent of claims in 2008. The denial rate has improved since 2003 when, according to an article provided by the Hospice & Palliative Care Association of New York State, Medicare denied 13 percent of claims. When you file a Medicare claim, there is a chance that it could be denied. In an effort to protect your rights and to ensure that correct decisions are made, a Medicare appeals process is in place.

Instructions

• 1

  Contact your doctors and health care providers. According to the official government website for Medicare, you should ask your doctors and health care providers to supply information "that may help your case." Items that may help your case include medical opinion letters, billing statements and medical records.

• 2

  Consider having someone assist you in your appeal. According to Legal Services of New Jersey, Medicare recipients "have the right to have someone help them with an appeal." You can appoint a family member, friend, doctor, attorney or anyone else you believe can help you through the process. Fill out form CMS-1696 to appoint a representative to help you.

• 3

  Complete and file CMS-20027, the Medicare Redetermination Request Form. This form initiates the first step in the appeals process. This form must be filed within 120 days from the date you received the claim decision. You must list the reason why you disagree with the determination. If you have evidence to support your appeal, attach copies of the evidence to the form.

• 4

  Complete and file CMS-20033, the Medicare Reconsideration Request Form. This is the second step in the appeals process. If the redetermination was upheld, you can ask for a reconsideration. This must be submitted within 180 days after the redetermination date. The reconsideration form mirrors the redetermination form.

• 5

  Complete and file form CMS-20034A/B, the Request for Medicare Hearing by an Administrative Law Judge (ALJ). There must be at least $100 at issue in the claim for an ALJ to hear the claim (as of 2010). The request must be made within 60 days after the reconsideration decision. Any written evidence, including reports and statements from the first two levels of appeal, must be submitted to the court.

• 6

  Complete and file DAB-101, the Medicare Appeals Council Appeal Form. This is the fourth level of the appeal process. This request must be made within 60 days after the administrative law judge decision. At this hearing, the Medicare Appeals Council (MAC) considers all evidence and transcripts from the administrative law hearing. The MAC may adopt the administrative law hearing's decisions, amend it in some way or send it back to the administrative law judge for reconsideration.

• 7

  Appeal the decision to the federal district court in the district where the beneficiary lives or has a principal place of business. The request must be made within 60 days after the MAC decision. There must be at least $1,050 at issue (as of December 2010). New evidence cannot be presented at this level.