If you need care immediately, and your health, life or ability to regain maximum function would be at risk if you were to wait the standard timeframe for your plan to review your case, you may be entitled to a fast review (expedited reconsideration).
In order to request a fast review, your plan must have officially denied you care. If your doctor will not give you a treatment because he knows your plan generally will not cover it, this is not an official denial. It may also not be an official denial if your doctor’s office calls your plan, and a representative tells them that a service will not be covered for you.
You should have your doctor’s office call your plan and ask that the service be covered for you. The doctor should request that the plan make an expedited decision because waiting the standard timeframe would endanger your health. (The plan must grant a doctor’s request for an expedited determination but does not have to do so for you.) If the plan decides it will expedite its decision, the plan must respond about whether it will cover the service within 72 hours.
Below are the steps you must take to file an expedited appeal.
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.
Have your doctor call or send a fax.
Have your doctor call or send a fax requesting an expedited reconsideration. You can request a reconsideration yourself, but the plan can choose whether or not to grant it. The plan must grant a doctor’s request.
Get the plan’s decision.
If the plan expedites the reconsideration, it must make a decision within 72 hours of your request for the appeal. (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 the HMO refuses to expedite the appeal you filed, you can file a complaint with the HMO and it has 24 hours to review the complaint.
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.
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.
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.
If you choose to continue to 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 reconsideration 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.