If your plan is refusing to pay for care you already received, you have the right to appeal. There are several stages to the process and deadlines you must meet.
Note: If your plan will not approve care that you need and have not yet gotten, you are entitled to a faster appeal.
Below are the steps you must take to file a “standard” appeal if your plan will not pay for care you already received. Make sure to keep any notices you receive from the plan and write down the names of any representatives you speak to and when you spoke to them.
- Get a Denial Notice
The plan must send you a written denial notice before you can start the appeal.
The notice will tell you what information you need to send to the plan to start an appeal.
It should also state the reason why the plan is denying coverage.
- Request a Reconsideration
You have 60 days from the date on your denial notice to appeal to the plan (request a reconsideration).
In most cases, you will need to send a letter to the plan explaining why you needed the service. Ideally, you should also include a supporting statement from your doctor that addresses the plan’s reason for denying care and explains why you needed the care (medical necessity).
- Get the Plan’s Decision
Once you appeal, the Medicare private health plan must make a decision within 60 days. If you do not hear back, call the plan.
- Get an Independent Review
If your plan still does not change its decision, it must forward your request to the next level of appeal—the Independent Review Entity (IRE) —automatically. The IRE is an independent group of doctors and other professionals that contracts with Medicare to ensure that you receive quality care.
The IRE must decide your case within 60 days.
- Continue to Additional Levels of Appeals
If the IRE says the plan does not have to pay for the care you received (upholds the plan's denial), you must take active steps to continue the appeal.You can appeal to an Administrative Law Judge (ALJ) (if the cost for the service in dispute is at least $140 in 2013). You must appeal to the ALJ within 60 days of the date on the IRE’s decision.
If you are turned down at the ALJ level, you can appeal to the Medicare Appeals Council (MAC) and then to Federal Court.
If you plan to appeal at the ALJ level or higher, you may want to find an advocate or lawyer to help you.