You can appeal.
If you are being prescribed a service—for example a test or a surgery—or you need to see a specialist, and your plan refuses to agree to pay for this care (grant you prior authorization), you can file an appeal.
Note: If you are being denied coverage for a prescription drug, you must use the Medicare private drug plan “exceptions” process to ask your health plan to cover a drug you need. There are several steps to the appeals process and deadlines you must meet. Below are the steps you must take to file a “standard” appeal for care.
Get a denial from the Plan
You will need the plan to make an official decision before you can start the appeal. You will generally need this decision in writing. If your doctor or plan denied care, you should call and ask the plan to send you a denial notice. If you called the plan to request that they cover a service (for example, you requested prior authorization—special permission—to see a specialist), and the plan representative said no, remind the person to send you the decision in writing.
The plan should mail you a denial notice within approximately two weeks. The notice will tell you what information you need to send to the plan to start an appeal and where to send it. It should also state the reason why the plan is denying coverage.
Note: If you don't get a denial notice within two weeks, you can file an appeal without it unless you've received word from the plan that they need extra time to review your case (they can extend by up to two weeks). Send a letter to your plan explaining that it has been 14 days and you have not received a denial notice. Include a doctor’s supporting statement explaining why you need the care. In doing this, you will be starting the next part of the process, “requesting a reconsideration.”
Request a Reconsideration
You have 60 days from the date on your denial notice to appeal the plan’s decision (request a reconsideration).
In most cases, you will need to send a letter to the plan explaining why you need the service. Ideally, you should also include a supporting statement from your doctor addressing the plan’s reason for denying care and explaining why you need the care (medical necessity).
Get the Plan's Decision
Once you appeal, the plan must make a decision within 30 days. (The plan has 14 extra days to gather information if it is in your best interest, but must notify you if it needs this extra time). If you do not hear back, call the plan.
Get an Independent Review
If your plan does not change its decision, it must forward your request to the next level of appeal—the Independent Review Entity (IRE) —automatically. An IRE is an independent group of doctors and other professionals that contracts with Medicare to ensure that you receive quality care. An IRE is an independent organization hired by Medicare to review appeals of health plan decisions.
The IRE must decide your case within 30 days.
If necessary, 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 reconsideration notice.
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.
If it is during an enrollment period, you may want to consider disenrolling to take Original Medicare, or changing to another private health plan if you can find one that covers what you need.
Note: Plans must meet deadlines for processing requests within the timeframes stated below but are technically required by law to do so as quickly as your health requires. 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.
