04 Medicare Appeals

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This is an audio broadcast prepared by California Health Advocates entitled “Medicare Appeals.” In this broadcast, we will briefly go over important appeal rights if Medicare, your Medicare Advantage plan, or your Part D prescription drug plan denies payment for, or coverage of, services.

Note: An appeal is a special kind of procedure you follow if you disagree with a decision about your health care. It is a way to deal with a complaint about a treatment decision or service not covered. A grievance is different. A grievance is a complaint about the way your Medicare health plan or provider is providing care. For example, you may file a grievance if you have problems with cleanliness of the facility, ease in reaching the plan’s customer service department, staff behavior, and/or operating hours. In this broadcast, we only discuss appeals.

1) If Your Medicare Part A or B Claim is Denied

If you have Original fee-for-service Medicare you have the right to appeal any decision about your Medicare services. If Medicare does not pay for an item or service, or if you are not provided an item or service you think you should receive, you can appeal. Here, we’ll first discuss if Medicare doesn’t pay for an item or service you’ve already received.

If Medicare Doesn’t Pay for an Item or Service You Already Received

When Medicare processes a claim for Medicare coverage or payment, you are sent a Medicare Summary Notice (MSN). This notice tells you whether or not Medicare will pay for the services and how much you must pay. If Medicare will not pay for the services, the MSN should provide the reason why coverage is denied. If you are not satisfied with Medicare’s determination, you may file an appeal. Instructions on how to appeal are written on this notice.

The first step in the appeals process for Part A and B services is known as a Redetermination. If you want to appeal Medicare’s initial determination or decision (as noted on your Medicare Summary Notice), you must submit a written, signed request for redetermination within 120 days (approximately 4 months) of the initial determination. The Medicare Summary Notice will direct you where and how to file the request. Medicare must issue a second decision within 60 days. If this decision is still not in your favor, you can request a Reconsideration, which is step 2 of 5 in this appeals process. Reconsiderations and the remaining appeals process steps are described further in the appeals section of our website.

If Medicare Terminates or Doesn’t Provide a Service You Require

If you face a termination of services from a hospital, skilled nursing facility, home health agency, hospice or comprehensive outpatient rehabilitation facility, you may request an expedited appeal. If you are receiving one of these services, you must receive a notice of termination or discharge no later than 2 visits or 2 days before the proposed end of services.

You may appeal if you disagree with the termination and, if the services are from a home health agency or comprehensive outpatient rehabilitation facility, a doctor certifies that failure to continue the service may place your health at significant risk. You can appeal this decision to the Quality Improvement Organization (QIO), which in California is Health Services Advisory Group (HSAG).

You must request the appeal by noon of the day prior to termination of services (this can be done by phone or in writing). You may contact California’s Quality Improvement Organization, HSAG at 1-800-841-1602, or 1-800-881-5980 (TDD for the hearing impaired). If you disagree with HSAG’s decision, you can request a Reconsideration by the Qualified Independent Contractor, which is Maximus CHDR. Information about this and further stages of appeal can be found on our website.

If you are hospitalized, and you feel that you are being discharged too soon, you should ask for a hospital discharge notice in writing. In order to appeal a hospital discharge, you can contact the Medicare contractor we just mentioned, Health Services Advisory Group (HSAG), at 1-800-841-1602, or 1-800-881-5980 (TDD for the hearing impaired).

2) If Your Medicare Part C (Medicare Advantage) Claim is Denied

If you are in a Medicare Advantage plan (such as an HMO, PPO, Private Fee for Service plan or Special Needs Plan), different rules apply when a service or treatment is denied by your plan. Depending on what services are being denied, and whether your health is in danger, there are different types of Medicare Advantage (MA) appeals:

  • the standard appeals process;
  • expedited appeals (if your health or life are at risk); and
  • fast-track appeals (if you are being discharged from a hospital, or if certain services are being terminated, such as skilled nursing facility or home health).

Under the following situations, you can appeal your Medicare Advantage plan’s decisions:

    1. If you have been denied payment for using medical services received outside the MA plan in an emergency or urgent care situation, or for using other medical services when you couldn’t get the care you needed within the MA plan.
    2. If your MA plan refused to give you or failed to give you treatment in a timely manner that you feel would otherwise be covered by Medicare. (In some cases, an expedited appeal may be in order.)
    3. If your MA plan discontinues services you believe are still medically necessary.

Standard Appeals

If you asked your Medicare Advantage plan to provide or pay for a service or item that you think should be covered or continued, the plan’s response or decision is called an organization determination. If the plan decides not to cover or continue a service or item, it must inform you in writing and include reason(s) for denying the service or item, and how to appeal the organization determination.

If a written notice is not given within 14 calendar days for a requested service, or within 30 days for a requested payment, you may treat the situation as a denial and request reconsideration by the plan, which is the first step in the appeals process. You may also request a reconsideration if your plan gives you a decision, but you are not satisfied with it. You have 60 days to request a reconsideration in writing. If your Medicare Advantage plan does not reverse its denial, the appeal must be forwarded to an Independent Review Entity (IRE) within 24 hours by the MA plan. For more information about this and additional steps in the Medicare Advantage appeals process, visit our website.

Expedited Appeals

An expedited appeal is a faster way to have your request for services addressed. Many medical conditions require immediate action when a service has been denied or terminated. Patients whose health or life would be at risk of deterioration or death are good candidates for an expedited appeal.

When a doctor requests an expedited appeal, the Medicare Advantage plan must review the case within 72 hours. This doctor does not need to be the one assigned to the patient (primary care physician), nor does the doctor need to be a member of the patient’s Medicare Advantage plan. If the expedited appeal request is made by the patient or patient’s advocate, the MA plan will review the request and either grant or deny it. If approved, the appeal occurs within 72 hours. If denied, the appeal goes through the standard 14-day appeal process.

Fast-Track Appeals

If you feel you are being discharged from the hospital before you are ready, you have the right to request a fast-track appeal through California’s Quality Improvement Organization (QIO), Health Services Advisory Group (HSAG).

You also have the right to request a fast-track appeal through HSAG if your Medicare Advantage coverage for services in a skilled nursing facility, home health care agency or a comprehensive rehabilitation facility are about to end.

At least 2 days before your coverage ends for any of these services, your Medicare Advantage plan must give you and your provider a notice. To make a fast-track appeal, follow the instructions on the notice and request an appeal by noon on the following day (the day after you receive the notice). You can also call HSAG at 1-800-841-1602 or 1-800-881-5980 (TDD-hearing impaired).

3) If Your Medicare Part D Claim is Denied

Medicare Part D has its own appeals process for denied coverage. Similar to Medicare Advantage appeals, there is an expedited appeals process if your health or life is at risk.

If your pharmacist tells you that your Medicare drug plan won’t cover a drug you think should be covered, or it will cover the drug but at a higher cost than you think you are required to pay, you have the right to request a coverage determination from your plan. This is the first step in your Part D appeals process. You can also request a coverage determination if your plan or pharmacist tells you that:

  • You must get prior approval first for your drug
  • You must try another drug before it pays for the drug first prescribed for you
  • There is a limit on the quantity or dose of the drug prescribed
  • And you or your doctor disagrees with any of the above.

Note that a Part D plan also issues a coverage determination in response to an exceptions request made by enrollees. This type of request requires you to submit a supporting statement from your doctor explaining why you need the drug you are requesting. Exception requests are made when enrollees seek their plan to grant an exception to plan rules regarding the drugs it covers on its formulary and the cost-sharing it charges for those drugs.

You, your doctor, family member, or other appointed representative can call your plan or write a letter requesting a coverage determination for the plan to cover the prescription you need. Once the request is received, the plan has 72 hours or 24 hours to notify you of its decision, depending on the type of request made:

  • The plan will have 72 hours if you have submitted a standard request for coverage or a request to pay you back.
  • The plan will have 24 hours if you have submitted an expedited request for coverage. Your request will be expedited if your doctor tells your plan that your life or health will be seriously jeopardized by waiting for a standard decision. It can also be expedited at the discretion of the plan if you yourself request the faster review, but don’t have your doctor’s support.

The plan may first notify you of its decision within 24 hours by telephone, but it must also mail you a written expedited coverage determination letter within 3 calendar days after they verbally inform you of their decision. If the plan does not give you a written notice about its expedited determination within these timeframes, the plan must send your request for expedited coverage determination to the next level of appeal in the Part D appeals process.

If the plan’s coverage determination is not in your favor (including its response to an exceptions request), you can appeal the decision within 60 days. The first level of appeal is called a redetermination, and it is done by the plan. Similar to the request for coverage determination, you can request that this process be expedited if your life or health is at risk. For more information about the Part D appeals process, visit our website.

4) Where to get more help and information

Medicare appeals can be complicated, and there are strict timeframes that apply, meaning that in order to assert your rights, you have to act before these timeframes expire. If you would like to talk to someone to learn more about your options to appeal decisions by Medicare, your Medicare Advantage plan, or Part D plan, you can get free individual counseling by calling the Health Insurance Counseling & Advocacy Program (HICAP), with offices in every county in California and a toll-free hotline. HICAP is a volunteer-supported program that provides unbiased information to help Medicare beneficiaries make the best choices for their individual health care needs. The California Department of Aging administers HICAP services.

Call 1-800-434-0222

Also, remember to visit our website at www.cahealthadvocates.org. This has been an audio broadcast produced by California Health Advocates. Thanks for listening.