What if you have Medicare and you need an item or service, but you find it isn’t covered? You have certain appeal rights if coverage is denied, including coverage of a prescription drug you need.
If Original Medicare, or your Medicare Advantage plan or Prescription Drug Plan, denies a service or item that you think you need, you can appeal that decision. You can also file an appeal if you’re being billed for a service or item that you already received, and you think Medicare or your Medicare plan should cover the entire bill, or you don’t agree with the amount you’ve been billed.
The appeal process is somewhat different depending on the denied item or service and whether you’re filing an appeal with Original Medicare or with a Medicare Advantage plan or Prescription Drug Plan.
How do I know with whom to file an appeal?
First you need to determine who provides your Medicare services and items.
- If you’re enrolled in Original Medicare, Part A and Part B, file your appeal with Medicare. Look at the quarterly (3-month period) statement Medicare sends you, called a Medicare Summary Notice (MSN). It lists all your items and services that providers and suppliers billed to Medicare during that 3-month period, how much Medicare paid, and how much you may have been charged and how much you may owe the provider or supplier. It also shows whether Medicare fully or partially denied any services or items. This is the first determination, and it’s made by the company that handles claims for Medicare. The MSN includes instructions for filing an appeal.
- If you have a Medicare Supplement (Medigap) plan, contact your State Health Insurance Assistance Program (SHIP) for information about filing an appeal.
- If you have prescription drug coverage through a stand-alone Medicare Part D Prescription Drug Plan, file your appeal through your Medicare Part D Prescription Drug Plan.
- If you’re enrolled in a Medicare Advantage (Medicare Part C) plan, file your appeal through that plan. Medicare Advantage plans often include prescription drug coverage, so if you get your drug coverage through a Medicare Advantage plan, that’s where you’d go first to file an appeal.
If you have a Medicare Part D Prescription Drug Plan or a Medicare Advantage Prescription Drug plan, look at the information they sent you when you enrolled to find out how to file an appeal. The plan’s website might also have this information, or you can call the plan. Look for the contact information on your plan membership card.
What are my appeal rights under Medicare Part D?
If you have Medicare prescription drug coverage, either through a stand-alone Medicare Part D Prescription Drug Plan or through a Medicare Advantage Prescription Drug plan, you have a right to request a coverage determination. A coverage determination is any determination (i.e., an approval or denial) made by the plan to cover a medication that you or your prescribing doctor believes you need. The following are types of coverage determinations:
- A formulary exception if you or your prescribing doctor believe you need a medication that’s not in your plan’s formulary (the list of covered drugs).
- A tiering exception if you or your prescribing doctor believe that you should pay less for a high-tier (more costly) drug because a lower-tier drug in the plan’s formulary wouldn’t work in your situation.
- A prior authorization for a medication that must be determined medically necessary for your condition to be covered by your plan.
If your plan denies the coverage determination request, you may appeal their decision.
What are my appeal rights under Medicare Part C?
If you have Medicare Part C (Medicare Advantage), you have the right to ask your plan for an “organization determination.” This is your plan’s initial decision about whether your plan will cover (or continue to cover) specific health services or items for you. You or your health-care provider can ask for this determination before you get the service (often called a prior authorization) or afterwards by submitting a claim for reimbursement.
If your Medicare Advantage plan denies the prior authorization request or claim for payment, you can appeal the denial.
What are my rights if I want to extend Medicare coverage of services?
If you’re getting Medicare services at a hospital, home health agency, skilled nursing facility, hospice, or comprehensive outpatient rehabilitation facility, and you feel your Medicare-covered services are ending too soon, you have the right to a “fast appeal.” Before your covered services end, your health-care provider should give you a notice that explains how to request a fast appeal. If you do not receive this notice, ask for it!
Original Medicare, or your Medicare Advantage plan or Medicare Prescription Drug Plan, sends you a notice when it reaches a decision about your appeal. There are five levels to Medicare’s appeals process. If you disagree with the decision made at any level of the process, you advance to the next level if your appeal meets certain criteria. At each level, you’ll be given instructions in the decision letter on how to move to the next level of appeal.
For help filing an appeal, you can do either of the following:
- Contact your State Health Insurance Assistance Program (SHIP).
- Call Medicare at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. Representatives are available 24 hours a day, seven days a week.
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