How to Fight Medicare Health Insurance Providers

Medicare is a federal health insurance program for the elderly, certain disabled individuals and other qualifying groups. The federal government directly manages Part A hospital benefits and Part B medical benefits. However, private insurance companies offer coverage that is designed to supplement and/or expand upon original Medicare coverage. These include Part D prescription drug, Medicare Advantage and Medigap plans. If Medicare refuses to provide coverage, you have the right to file an appeal.

Instructions

• 1

  Contact the medical provider(s) who provided the services that Medicare is denying payment for. Obtain documentation from these providers supporting your appeal, including information documenting why the services were medically necessary.

• 2

  Complete form CMS-20027 from the Medicare.gov website in References below. This is the initial appeal form. This form requires inputting your Medicare number, date of service(s), items of services provided and a statement including reasons why the claim is being appealed. Call (800) MEDICARE to obtain information regarding where to send the completed form. This form must be submitted within 120 days of receiving the denial claim. If your initial appeal is denied, continue to step 3.

• 3

  Complete form CMS-20033 from the Medicare.gov website. This is your second appeal and is reviewed by a qualified independent contractor, not a Medicare employee. This form requires similar information to the initial appeal's form. You also have the right to submit additional evidence with this form. This form must be submitted within 180 days of receiving the decision of the initial appeal. If this appeal results in a denial, continue to step 4.

• 4

  Complete form CMS-20034A/B from the Medicare.gov website. This is your third and final appeal. Your case is heard by an administrative law judge (ALJ). This hearing is typically held in a courtroom at a regional Social Security Administration (SSA) office. You will be able to testify during this hearing and submit new evidence. If you do not want to have a hearing but want an ALJ to review the appeal based on submitted evidence, you have the right to deny the hearing. This appeal must be sent within 60 days of receiving the decision for the second appeal. The appeal must be for medical costs greater than $120.