Medicare Advantage Appeals Process

Medicare offers health coverage to the elderly and disabled citizens of the United States. Most people get their care straight from the federal government, but many choose to receive benefits through private plans called Medicare Advantage. One of the biggest downsides of Medicare Advantage plans is the fact that they can deny you care or services. Fortunately, Medicare requires that Medicare Advantage plans offer beneficiaries an appeals process to prevent unfair denial.

Instructions

• 1

  Wait for a denial notice to come in the mail. The denial notice is the official decision, and the appeals process usually cannot start until you receive this in writing. If you received denied care verbally, ask for the decision in writing. Wait two weeks for the denial. If you do not receive it within two weeks, you can start the appeals process without it.

• 2

  Request a reconsideration of their decision. Note the date on the denial notice. You will have 60 days from this date to complete this step. Bring the denial notice to your doctor, and have your doctor write a letter explaining why the service or care is medically necessary. You should also write a letter that is similar to your doctor's. Submit this letter either by fax or certified mail to your plan's Appeals & Grievances department which should be listed on your denial letter.

• 3

  Wait up to 30 days for the plan to respond. If the plan needs more than 30 days, then they must notify you. If they do not respond within 30 days, continue your appeal using the proof of when you sent the appeal (certified mail receipt or fax receipt). If you receive a positive decision, then your appeals process ends here, and your plan must now cover the service. If you received another denial, then you must escalate the appeal to another level.

• 4

  Change any letters to reflect your plan's reason for denial. They must supply a reason for denying your service, such as insufficient evidence or that your service is not medically necessary. If this is the case, you and your doctor must strengthen your letters to address this reason for denial.

• 5

  Forward the appeal to the Independent Review Entity. This is a group of professionals contracted by Medicare to act as an unbiased entity that reviews appeals. They are not affiliated with your health care plan. Your second decision should have the address for the Independent Review Entity named Maximus.

• 6

  Repeat these steps for all continuing levels of appeal. If the Independent Review Entity denies your appeal, then you can escalate it to an Administrative Law Judge if your dispute is worth at least $130 in 2010. From there you escalate it to the Medicare Appeals Council and then finally to Federal Court. From the Administrative Law Judge level or higher, Medicare Interactive recommends seeking legal council.