Medicare Advantage appeals are not pleasant.
You have Medicare Advantage.
You thought you were covered on the medical claim you submitted.
Unfortunately, your claim was denied.
What can you do?
According to a recent Centers for Medicare & Medicaid document titled “Medicare Managed Care” and Health and Human Services instructions titled “Level 1 Appeals: Medicare Advantage (Part C),” you can appeal the decision.
The answer depends on the type of plan you have.
If you have a Medicare Advantage plan, the appeal may pass through five levels.
What are they?
The first levels of appeal is considered a “request for consideration.”
This is triggered when your Medicare Advantage plan provides you one of three organizational determinations.
These include notice of your plan either not paying for a service, not allowing a service, or a no longer providing a service.
From the date of the notice, you have 60 days to submit and appeal.
The plan providers will review your claim and must notify you of a decision within 30 days for a request of service and 60 days for a payment request.
If your service is a time sensitive, your doctor can submit a request for expedited review.
If you are receiving inpatient services at a hospital, nursing home, or assisted living facility, then an immediate review may be requested.
If the claim is still denied or fails to meet the deadline, the appeal will automatically pass to level two.
Level two sends the appeal to an Independent Review Entity (IRE).
The role of these outside parties is to review the decision and appeal to determine whether the claim is medically necessary and should be covered.
The Medicare Advantage appeals decision will be provided by mail.
If the response is not to your liking and meets the minimum amount guidelines, you file a level three appeal within 60 days.
[Are we having fun yet?]
A level three appeal is handled by the Office of Medicare Hearings and Appeals (OMHA).
If the case meets specific guidelines, an OMHA adjudicator may hold hearings.
Should the decision still not be to your liking, you can request the fourth level for appeal.
This Medicare Appeals Council conducts this review and determination.
The final appeal one can make is the fifth level of appeal, if you meet procedural requirements.
The fifth level of appeal is a judicial review in your local Federal District Court.
You can pursue this if the Medicare Appeals Council gives you notice of their decision and information about filing a civil lawsuit.
This appeal processes can drag on for months.
If you require a Medicare Advantage appeal, enlisting the help of an experienced elder law attorney may be beneficial.
References: Centers for Medicare & Medicaid. (accessed November 7, 2019) “Medicare Managed Care.”
Health & Human Services. (accessed November 7, 2019)“Level 1 Appeals: Medicare Advantage (Part C).”