04 Medicare Appeals



Ideally, Medicare will pay its share of your health costs without you having to do anything. You are entitled to file an appeal if you are found ineligible to participate in the Medicare program. If you need help filing an appeal with an ALJ, call (800) MEDICARE (800) 633-4227), or your local legal services office. If your appeal is denied, you may file another appeal with an independent contractor, called a Qualified Independent Contractor, that was not involved in the original decision.

You must file your OMHA level appeal within 60 days of the date on your IRE denial letter. HICAP is a volunteer-supported program that provides unbiased information to help Medicare beneficiaries make the best choices for their individual health care needs.

When you appeal at the hearing level, you will have a much better shot at a quick response time if you clearly mark your appeal and the envelope you send it in as a "Beneficiary Appeal" to distinguish it from provider appeals, said Terry Berthelot, a senior attorney at the Center for Medicare Advocacy.

Appealing a Part C denial: Part C plans, also known as Medicare Advantage plans, are provided by private insurance companies. You also may file an appeal if you believe that Medicare has failed to pay the proper amount for services or if coverage has been denied for a particular service.

If our plan denies your appeal for a Part D prescription drug, How to Appeal Medicare Advantage Denial you will need to choose whether to accept this decision or appeal it to Level 2. The notice we send you denying your Level 1 Appeal will include instructions on how to make a Level 2 Appeal, including who can make the appeal, deadlines you must follow, and how to reach the review organization.

Reconsiderations and the remaining appeals process steps are described further in the appeals section of our website. CMS audits have also highlighted widespread and persistent performance problems with MAOs related to denials of care and payment, OIG states.

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