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Original Medicare: Claims: Appeals

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If your Medicare claim is denied, appeal -- and keep appealing until you get the care you need.

If Medicare denies your claim, you have 120 days to request a "redetermination" of the decision. It is up to you to explain why Medicare should cover the claim and to include evidence.

If your Medicare appeal is denied, you have the right to file up to four more appeals. It is worth fighting because your odds of success improve each time. For more information, see the other sections of this article.

Before appealing, call your doctor's office and confirm that the correct code was used for the service about which the claim was submitted. Miscoding can be a reason for denial of a claim. If there was an error, contact the claim denier.

Assistance is available to help with an appeal.

The first appeal

You have 120 days to reqwuest a "redetermination" of the decision denying your claim.

The letter denying your claim states the reason for the denial. It's up to you to prove that the denial is not correct.

Show your doctor the denial papers and ask that he or she write a letter which responds to each of the points raised in the denial and which states that the subject health care is necessary. Ask the doctor to include any and all evidence which backs up the doctor's statements.

The form to use to request the redetermination is the Medicare Redetermination Request Form (Form CMS-20027). It is available by calling 800.633.4227 or online at:www.cms.hhs.gov/cmsforms/downloads/cms20027.pdf offsite link. The denial form you received includes instructions about where and how to submit this form.

Attach a copy of the doctor's letter and any attachments with your appeals form. Keep a copy of the completed form and the doctor's letter and attachments, if any, with your Medicare file.

Send in the form in a timely manner in such a way that you can get a receipt showing the date that the form was received (for example, U.S. Post Office, Return Receipt Requested, or any of the overnight services).

Professional help is available if you need it to complete the form.

Appeal #2

If your claim is denied after your first appeal, you have 180 days from the date your redetermeination request is denied to request the next appeal. This appeal is to a Qualified Independent Contractor (QIC). The request is for a "reconsideration determination."

The form to use for this appeal is Form CMS-20033 which is available at http://www.cms.hhs.gov/cmsforms/downloads/cms20033.pdf  offsite linkor by calling 800.633.4227.

Ask your doctor if there is additional evidence he or she could add to the first letter to provide additional reasons why your request should be granted. For example, the requested service is standard practice in the area in which you live, or at the country's best hospitals.

If the denial provides additional reasons beyond those stated in the original denial, ask your doctor to write another letter refuting the new points.

When you send in the form:

  • Keep a copy of the completed form and attached evidence with your Medicare file.
  • Send the papers in such a manner that you have proof of receipt.

Appeal #3

If your claim is denied after your first appeal, you have 180 days from the date your redetermeination request is denied to request the next appeal. This appeal is to a Qualified Independent Contractor (QIC). The request is for a "reconsideration determination."

The form to use for this appeal is Form CMS-20033 which is available at http://www.cms.hhs.gov/cmsforms/downloads/cms20033.pdf  offsite linkor by calling 800.633.4227.

Ask your doctor if there is additional evidence he or she could add to the first letter to provide additional reasons why your request should be granted. For example, the requested service is standard practice in the area in which you live, or at the country's best hospitals.

If the denial provides additional reasons beyond those stated in the original denial, ask your doctor to write another letter refuting the new points.

When you send in the form:

  • Keep a copy of the completed form and attached evidence with your Medicare file.
  • Send the papers in such a manner that you have proof of receipt.

Appeal #4

If the Administrative Law Judge denies your appeal, you have 60 days to request a review by the Medicare Appeals Council.

The denial form from the Administrative Law Judge will include instructions about how to file your appeal.

Again, if you have new evidence supporting your claim, be sure to include it. New evidence gives the Council a hook on which to approve your claim. In any event, be sure the Council has all the evidence previously submitted.

Appeal #5

If the Medicare Appeals Council turns down your appeal, you have 60 days to go to court and file for a judicial review in Federal District Court. It is advisable to have an attorney represent you if you file for a judicial review.

For more information, contact the Department of Health and Human Services at www.hhs.gov/omha offsite link or Tel.: 877.696.6775.


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