Magellan Healthcare can help you take care of your Medicare coverage with support and resources to help you find the care you need. Read on to learn about the appeals process for Medicare coverage problems.
Filing an Appeal with Medicare
Medicare beneficiaries can file an appeal if Medicare denies a request for coverage of a health care service, supply, item, or drug. These requests may be called exceptions: you and your doctor request an exception for coverage if Medicare does not cover the care. Many prescription drug plans, for example, cover certain drugs with quantity limits. If your prescriber decides you need a higher quantity than is covered, you file an exception.
Sometimes these exceptions are denied, which is where the appeal comes in. Filing an appeal requires filling out forms or sending a written request to the claims company. You will need to include information such as your name, address, and Medicare number, the specific items or services and dates of those services that you are requesting a redetermination for, an explanation for why they should be covered, the name of your representative, and any further supporting details that can help your case.
You will get a decision within 60 calendar days unless you have filed an expedited request. There are five levels of appeals, and you will get instructions on how to move to the next level if you are denied again.
The paperwork and processes can differ based on the plan you request coverage from. Read on for a few different appeals comparisons.
With Original Medicare
Look at your Medicare Summary Notice (MSN), which will tell you when to submit your appeal. You can still file if you’ve missed the deadline if you prove you had a good reason to miss it.
Fill out the Redetermination Request Form or write up a request. In the written request, include your name, address, and Medicare Number; identify the items and services you disagree with and the dates of service; explain why the services should be covered; name your representative, if you have one; and give any other details that can support your case.
Send the form or request to the company listed under the appeals section in your MSN.
Medicare Advantage Appeals
With a Medicare Advantage plan, your appeals process is slightly different. The date to file your appeal is 60 days from the date of the denial notice. Look at the plan membership card to find contact information and get help with this process.
You must prepare a written request with all items mentioned under Original Medicare. If the wait for a decision could jeopardize your life, health, or ability to regain maximum function, you can receive an expedited decision within 72 hours.
Medicare Part D Plan Problems
Medicare Part D has a different form for coverage problems, called the Model Coverage Determination Request form. You can fill this out if you need reimbursement for covered drugs you’ve purchased or need a prescription and have to file for an exception.
To file for these coverage problems, you can complete and send a Model Coverage Determination Request form. This is a good way to document your needs and make sure you check all the boxes. Alternatively, you can write your plan a letter, call them, or have your prescriber provide a statement explaining the medical reason for an exception.
