How to Appeal a Medicare HMO Denial

A Medicare Health Maintenance Organization (HMO) is an HMO that has contracted with the federal government to provide services under the Medicare Advantage program. Patients with the HMO are able to access health care through their HMO as opposed to through the traditional fee-for-service Medicare program. But appealing a denial of medical coverage from a Medicare HMO can be a difficult process. Many people with Medicare HMOs believe it is more challenging to appeal a Medicare HMO denial than one from a traditional insurance company. This is mainly because traditional insurance companies are private corporations, whereas Medicare HMOs are managed by the government. However, many people have successfully appealed Medicare HMO denials and have acquired funding for necessary medical procedures. Organization and persistence are key when appealing a Medicare HMO denial.

Instructions

How to Appeal a Medicare HMO Denial

• 1

  Read the Medical Summary Notice (MSN) that you receive from your Medicare HMO. The MSN will list all of the services billed to the Medicare HMO within the last 90 days. Any services that were denied will be listed on the MSN with instructions on how to appeal the denial. Contact the customer service hotline listed on the MSN to obtain information about why the service was denied.

• 2

  Obtain a letter of medical necessity from your physician explaining why the medical procedure that has been denied is necessary. Ensure your physician also explains how not obtaining funding for this necessary medical care will negatively impact your overall health.

• 3

  Obtain a second supporting opinion and letter of medical necessity from another physician. This will show your Medicare HMO that your medical procedures are truly necessary.

• 4

  Mail the letter of medical necessity along with an appeal form to your Medicare HMO. Ensure that the letter and form are mailed with delivery confirmation to verify they are received.

• 5

  Reply immediately to all correspondence initiated by the Medicare HMO. Appeal all denials. Include all relevant information pertaining to your case. For example, if you have developed another medical condition as a result of your current condition not being adequately treated, or if your current condition has worsened, be certain to include that information with your correspondence to your Medicare HMO.