Appealing a Medicare Claim

Allison Martin
Frustrated by medical bills

Have you been denied for treatment or assessed a fee for a service you thought was covered under your Medicare plan? If so, you have the right to appeal a claim decision.

When to File An Appeal

According to Medicare.gov, you should file an appeal if your plan denies any of the following requests:

  • A health care service, supply, item, or prescription drug that you deem necessary for treatment
  • A payment request for a healthcare service, supply, item, or prescription drug that is currently in your possession
  • A request to alter the patient responsibility amount for a healthcare service, supply, item, or prescription drug
  • A request to continue providing a healthcare service, supply, item, or prescription drug you are currently receiving

The Appeal Process

There are five levels in the appeal process. Once the decision is reversed, it is not necessary to go to the next level.

Level 1: Redetermination by the Company that Handles Medicare Claims

Each quarter, you will receive a Medicare Summary Notice (MSN) that details:

  • Services and supplies rendered
  • Total costs
  • Amounts billed to your insurance provider
  • The remaining balance for you to pay

If you disagree with what is listed on the MSN, you can choose one of the three options listed below to file an appeal:

  • Complete the Redetermination Request form found on the Medicare website.
  • Follow the guidance listed on the MSN to submit a written complaint. When drafting this document, you will need to:
    • Circle the items or services in dispute.
    • Write your name, address, phone number, and Medicare number directly on the MSN.
    • Attach a written statement that includes your Medicare number, a detailed description of your grievance, and any other applicable documents to support your grievance.
  • Remit a written request to the claims department that includes:
    • Your name
    • Medicare number
    • Items and/or services along with dates, the reason for your appeal, and your signature

Level 2: Reconsideration by a Qualified Independent Contractor (QIC)

If your appeal is not approved at Level 1, you can submit a request for reconsideration to be completed by an independent contractor.

To move forward, you can choose either of the options listed below:

  • Complete the Medicare Reconsideration Request form found on the Medicare website.
  • Remit a written request to the QIC that includes:
    • Your name
    • Medicare number
    • Items and/or services in dispute along with dates, the reason for your appeal, and your signature

Level 3: Hearing Before an Administrative Law Judge (ALJ)

Assuming the reconsideration from a QIC at Level 2 is unsuccessful, you have a right to receive a hearing before an ALJ. However, you must have a patient responsibility of $150 or more.

To initiate the process, it is necessary to do one of the following:

  • Complete the Request for Medicare Hearing by an Administrative Law Judge form found on the website.
  • Remit a written request to the Office of Medicare Hearings and Appeals that includes:
    • Your name
    • Address
    • Medicare number
    • Appeal number from the QIC Reconsideration (from Level 2)
    • Items and/or services in dispute along with dates, the reason for your appeal, and any other supplemental materials that may strengthen your case.

Level 4: Review by the Medicare Appeals Council (MAC)

In the event you disagree with the decision rendered by the ALJ at Level 3, you can request an appeal via one of the following options:

Level 5: Judicial Review by a Federal District Court

As a last resort, you can request an appeal through the federal district court within 60 days if your claim amount equals $1,500 or more.

Further instructions on how to file an appeal beyond this level are listed in the decision letter issued by the MAC.

An Important Consideration

If you wish to file an appeal for a decision outside of original Medicare coverage, visit the links below for additional guidance as the standard appeal process varies:

Decision Timeline

You will receive an appeal decision via mail within 15 days.

Fast Appeals

In certain circumstances that may impair your livelihood, you have a right to a fast appeal. If the ruling is in your favor, you can continue to receive care, free of charge. However, you will still be responsible for any applicable deductibles and coinsurance amounts.

Other Useful Tips

There are a few actions you may want to consider taking before filing an appeal.

Gather Supporting Documentation

Before submitting an appeal, you will want to gather as much information as possible to support your case. Reach out to health care providers and suppliers, if applicable, to gather any relevant documentation. This includes, but is not limited to:

  • Treatment plans
  • X-rays
  • Medical evaluations
  • Blood work and other lab results
  • Medical referrals
  • Prescriptions

Seek Professional Assistance

If you prefer assistance with the appeals process, reach out to your State Health Insurance Assistance Program (SHIP) using the information found on this page. You also have the option to select someone to act on your behalf, but you will need to complete the Appointment of Representative form to move forward with the process.

A Final Thought

By educating yourself on the Medicare appeal process and seeking assistance when needed, you will strengthen your chances of receiving a redetermination in your favor. Furthermore, you will save hundreds, if not thousands, of dollars on your health care equipment and services.

Appealing a Medicare Claim