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The Medicare appeals process

You have the right to appeal if Medicare:

  • Denies a request for a health care service, supply, item or prescription drug that you think you should be able to get
  • Denies a request for payment of a health care service, supply, item or prescription drug you already got
  • Denies a request to change the amount you must pay for a health care service, supply, item or prescription drug
  • Stops providing or paying for all or part of a health care service, supply, item or prescription drug you think you still need

Source: Medicare.gov

Five-level Medicare appeal process

The Medicare claims appeal process has five levels:

  1. Redetermination. The first step in the Medicare appeals process is a review of the initial determination made by the company that handles Medicare claims. The initial determination is on the “Medicare Summary Notice” (MSN). MSNs are distributed every three months and indicate what part of your medical claim Medicare approved or denied, what Medicare paid to the provider and what you may owe to the provider. A redetermination request must be filed with 120 days of receipt of the MSN.
  2. Reconsideration. If you disagree with the redetermination made in the first step, you have 180 days in which to file an appeal of the decision. In this step, a reconsideration is conducted by a Qualified Independent Contractor (QIC). A QIC is a person who did not take part in your redetermination decision. After the QIC reviews your claim, you will receive a “Medicare Reconsideration Notice” notifying you of the decision.
  3. Administrative law judge (ALJ) hearing. If you disagree with the reconsideration decision or do not receive a reconsideration decision within 60 days, you have 60 days to request a hearing before an ALJ. The hearing is your opportunity to explain your case and position to an ALJ. The hearing will be conducted via video teleconference, telephone or in person.
  4. Medicare Appeals Council review. The next level after the ALJ hearing is review by the Appeals Council. If you disagree with the ALJ ruling or do not receive and ALJ decision within the specified time period, you have 60 days to request an Appeals Council review.
  5. Judicial review in U.S. District Court. The final level of Medicare claims appeal is judicial review in Federal District Court. If you disagree with the Appeals Council decision or do not receive a decision within the specified time period, you have 60 days to request judicial review.

Speak to a Medicare lawyer

If you have been denied Medicare benefits, contact a lawyer from Chayet & Danzo, LLC. We offer free consultations with an attorney experienced in handling Medicare appeals.

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