4 Steps to Appeal a Denied Medicare Advantage Claim
One day, you may open some correspondence from your Medicare Advantage insurer and discover that one of your claims has been denied. It is called a coverage or organization “determination.”
Or maybe you or your doctor asked your plan in advance for a determination to make sure a service would be covered. In either case, you will be facing the denial of a service or payment.
All too often, plan members think the process to contest a denial might be overwhelming and never bother to do so. Instead, they either pay the bill or ignore it, thinking it will disappear. But it won’t.
And that’s not the best solution. The Inspector General of the U.S. Department of Health and Human Services (HHS) found that 99% of those denied service or payment didn’t even file the first level of an appeal. So don’t be one of them.
Instead, take action by following these steps as appropriate:
Step One -- Prepare
Read through the denial notice carefully. Ensure you understand why the claim was denied so you can file an effective appeal. Denial notices can be unclear, or they can include incorrect information. If you need help understanding it, reach out to your plan provider, your doctor, your State Health Insurance Assistance Program (SHIP) or Medicare at 1-800-MEDICARE (1-800-633-4227). ] Gather information from anyone who can provide something that supports your case and keep copies of everything.
Takeaway action step: If you feel someone else could represent you better than you can, consider appointing a representative. A representative can be a friend, family member, advocate, doctor – anyone who agrees to advocate for you. Fill out an “Appointment of Representative” form entirely and submit it with any correspondence about further consideration of your denied request.
Timing is everything. You have 60 days from the date of the notice to file an appeal, called a request for “reconsideration.” So begin the process immediately rather than letting it go until you no longer have the time to prepare it carefully. Your request must be written unless your plan specifically lets you file an appeal by email, phone or fax.
Even if you don’t feel 100% certain of the process, follow the instructions your plan provider included with the denial notice. Here’s why:
HHS reports that when preauthorization and payment denials were appealed, 75% were overturned at the first level (and more at later levels). So filing an appeal can save you money.
One important detail: there’s not just one level of the appeals process. In fact, there are five. So if your denial is not reversed as you believe it should be, you always have the option of taking the appeal higher. And this time, you may have the arguments you overlooked when filing the first appeal. So anything is better than not filing at all.
Step Two – Submit the application
Be sure your fully completed application is submitted within the 60-day timeframe. Besides your name, address and Medicare number, you will need to identify the item you disagree with, the exact date you received the disputed service, an explanation of your reasons for disagreeing with their decision, and any other supporting information you have.
In the first appeal and any appeal after that, your Medicare number should be written on every document you submit, and you should keep a copy of everything submitted.
If you feel your health could be in danger by waiting the 14-day average for a decision, request a “fast” or “expedited” decision. Your insurer has to give you a decision within 72 hours if it feels (or your doctor says) that the standard decision time could be detrimental to your life, health or ability to regain maximum function.
Step Three – Monitor your appeal
Appeals are too important just to file and forget. Keep aware of any further information you receive that could support your case in the future, should you need to go to a further round of appeals.
Mark your calendar for when you should receive an answer. Depending on the type of request, this is how long your plan has to respond to your submitted appeal:
Expedited or fast request: 72 hours
Standard service request: 30 calendar days
Payment request: 60 calendar days
Your plan may notify you in writing that it is extending the time to complete a fast or standard request by up to 14 days if it needs more information from an out-of-network provider and if the extension is to your benefit. The notification will tell you why it is extending. It will also advise you of your right to file an expedited (or fast) grievance if you disagree with the extension.
When you get your response, if your appeal is partially or fully declined, it is sent automatically to level 2: an Independent Review Entity (IRE). Your plan may call its IRE a “Part C QIC.”
Step Four – Escalate your appeal
If you disagree with your Medicare Advantage insurer’s initial decision, you can file a level 2 appeal and repeat that process through three more levels. You will receive instructions on how to move to the following appeal level with each decision letter.
The five appeal levels are:
Level 1: Reconsideration from your plan
Takeaway action step: At any stage of this process, do not hesitate to seek help. It is available from your State Health Insurance Assistance Program (SHIP) and from Medicare.gov’s Live Chat or at 1-800-MEDICARE (1-800-633-4227).