Medicare Appeals Process & Exceptions
No one likes to find out that their Medicare claim has been denied. In the last two years, Medicare has imposed more than $10 million in fines and taken other enforcement actions against private plans for overcharging beneficiaries, denying or delaying coverage for prescription drugs, and failing to respond to patients' complaints.
If the plan's coverage determination is not in your favor (including its response to an exceptions request), you can appeal the decision within 60 days. With the very high rates of enrollment, even seemingly low rates of inappropriate denials can create significant problems for Medicare beneficiaries and their providers said the report.
Filing a Medicare appeal might seem intimidating, but it's worth a try. If you are unhappy with the ALJ Hearing decision, you may ask the Medicare Appeals Council (Council) to review your case. The costs of Medicare plans are strongly regulated How to Appeal Medicare Advantage Denial by the federal government.
For second-, third- and fourth-level appeals, you may want help. Instructions for reaching the next level of appeal can be found in the decision letter Medicare sends you at the end of any level. On September 26, the OIG published a Review of whether chiropractic services that Etheredge billed for complied with Medicare requirements.
Appeals can be processed on an expedited, fast-track timetable or at the standard, slower pace. An Appeal is a formal way of asking us to reconsider a decision that we have made about benefits or coverage. For example, the federal government encourages consumers to purchase H.S.A. (Health Savings Account) qualified H.D.H.P.'s (High Deductible Health Plans) so they have more control over how their health care dollars are spent.
The Office of Medicare Hearings and Appeals (OMHA) handles these appeals. Every Medicare Advantage plan must provide Medicare Part A (hospital insurance) and Part B (medical insurance) to its members. If your Medicare Advantage plan does not reverse its denial, the appeal must be forwarded to an Independent Review Entity (IRE) within 24 hours by the MA plan.