If you are enrolled in a Medicare Advantage Plan and were denied coverage for a health service or item before you received the service or item, you can appeal to ask your plan to reconsider its decision. If you believe the health service or item should be covered, you can follow the steps below.
Note: You will follow different appeal processes if your plan has denied coverage for care you have already received or a prescription drug.
Before you can indeed begin the appeal process, you will need to obtain an official written decision from your plan, called a Notice of Denial of Medical Coverage. You generally notified verbally that your plan would not cover a service or item when you or your doctor call to confirm coverage before the service is provided. If the plan tells you that the service or item will not be covered, they should also send you the Notice of Denial of Medical Coverage. You should receive this written denial within 14 days.
If you or your doctor feel as if your health could be tremendously affected by waiting for the standard timeline for an appeal decision, you can request an expedited appeal. If your plan approves your request to expedite, it should issue a decision within 72 hours.
Start your appeal by following the instructions on the Notice of Denial of Medical Coverage. Ensure you file your appeal within 60 days of the date on this notice. You will need to send a letter to your plan explaining why you need the service or item. You may also request your doctor write a letter of support, explaining why you need care and addressing the plan’s concerns. Your plan should make a decision within 30 days. If you file an expedited appeal, your plan should make a decision within 72 hours.
In some cases, your plan can extend its decision deadline up to 14 days. You will be notified if this happens.
If you don’t receive a Notice of Denial of Medical Coverage within two weeks (or 28 days if your plan extended its decision deadline), you can file an appeal without it. Start your appeal by sending a letter to your plan explaining that it has been two weeks since you initially requested an item or service, and you have not received a denial notice. If possible, include a doctor’s letter of support. You may also want to file a grievance.
If you have a good reason for missing your appeal deadline, you may be eligible for a good cause extension.
If the appeal is successful, your service or item will be covered. If your appeal is denied, you should receive a written denial notice. Your plan should also automatically forward your appeal to the next level, the Independent Review Entity (IRE). The IRE should make a decision within 30 days of the date on your plan denial notice. If you file an expedited appeal, the IRE should make a decision within 72 hours.
If your plan misses the 30-day decision deadline, your appeal will be considered denied, and your plan should automatically forward your appeal to the IRE.
If your appeal to the IRE is successful, your service or item will be covered. If your IRE appeal is denied and your service or item is worth at least $160 in 2017, you can choose to appeal to the Office of Medicare Hearings and Appeals (OMHA) level. You must file your OMHA level appeal within 60 days of the date on your IRE denial letter. If you decide to appeal to the OMHA level, you may want to contact a lawyer or legal services organization to help you with this or later steps in your appeal—but this is not required.
If your appeal to the OMHA level is successful, your service or item will be covered. If your appeal is denied and your service or item is worth at least $160 in 2017, you can appeal to the Council within 60 days of the date on your OMHA level denial letter. There is no decision timeframe for the Council to make a decision about your appeal.
If your appeal to the Council is successful, your service or item will be covered. If your appeal is denied and your service or item is worth at least $1,560 in 2017, you can appeal to the Federal District Court within 60 days of the date on your Council denial letter. There is no timeframe for the Federal District Court to make a decision about your appeal.
For more information or any additional questions you have regarding your plan, contact Medicare Pathways at 866-466-9118 to learn more.
