If you’re a Medicare beneficiary, you have the right to file a Medicare appeal of a decision made about your coverage. You also have other rights under the program, which include the right to file a grievance. Here’s what you need to know about the Medicare appeals process.
What is the difference between Medicare appeals and grievances?
Some people might use the terms “Medicare appeals” and “Medicare grievances” interchangeably, but they mean two very different things, and the process for resolving them is quite different. Under Medicare:
- A grievance is a complaint or dispute, not involving a coverage determination. The complaint could be about the care you received, or the actions or behavior of any Medicare health plan or prescription drug plan or provider. You can file a grievance simply to express your dissatisfaction with some aspect of your care or how you were treated.
- Medicare appeals are actions you take when you don’t agree with a coverage or payment decision Medicare or your Medicare health plan makes about your treatment. You may use the Medicare appeals process to try to reverse a decision made by Medicare or a Medicare-approved health plan. There are up to five levels to the appeals process.
How do you file Medicare appeals?
The Medicare appeals process differs slightly depending on whether you are enrolled in Original Medicare (Part A and Part B), or a Medicare Advantage plan, or if your dispute is over prescription drug coverage under a stand-alone Medicare Part D Prescription Drug Plan.
Original Medicare appeals
Depending on whether your Medicare appeal is granted or denied at each stage, there can be up to five levels of appeal.
Level 1: Your first step in the Medicare Appeals process
Your first step in filing an Original Medicare appeal, whether it concerns Part A or Part B, is to appeal the decision to the company managing your Medicare claims. You can do this in any of the following ways:
- Fill out this Medicare appeals form.
- Follow the instructions on the back of your Medicare Summary Notice (MSN) that’s mailed to you every three months.
- Write a letter to the claims company at the address on the back of your MSN.
You’ll generally get a decision about your Medicare appeal within about 60 days.
Level 2: Reconsideration Request for your Medicare appeal
If you disagree with the decision returned to you from Level 1, you have 180 days to file a request for reconsideration by a Qualified Independent Contractor (QIC).
To file this second level of Medicare appeal, which is reviewed by a QIC, complete and submit Medicare Reconsideration Request Form – 2nd Level of Appeal. You’ll receive a response, called a Reconsideration Notice, about 60 days after you file. You have 60 days from the date of the letter to proceed to Level 3, review before an administrative law judge.
Level 3: Medicare Appeals before an administrative law judge (ALJ)
You may request a hearing before an administrative law judge by submitting the form Request for an Administrative Law Judge Hearing or Review of Dismissal; you’ll receive information about the date of your hearing, which may take place in person, over the phone, or by video conference. The ALJ has 90 days to issue a determination about your appeal. If you are still dissatisfied, you may escalate your Medicare appeals to Level 4, review by the Medicare Appeals Council.
Level 4: Review by the Medicare Appeals Council
To request review by the Medicare Appeals Council, follow the directions on the back of the decision you received from the ALJ, or complete and submit the Request for Review of Administrative Law Judge Medicare Decision/Dismissal form. The Medicare Appeals Council must send you a written decision within 90 days of receiving your request, and you have 60 days to escalate your appeal to Level 5, judicial review by a federal district court, if you disagree with your decision.
Level 5: Judicial review by a federal district court
To qualify for this level of Medicare appeals, your dispute must be at least $ 1,630 in 2019. Follow the directions on the back of your decision from the Medicare Appeals Council to initiate this process.
If you have trouble at any point during the Medicare appeals process, you may contact your State Health Insurance Assistance Program (SHIP) or Medicare Ombudsman to get help. You can also call 1-800-MEDICARE 24 hours a day, 7 days a week (TTY users should call 1-877-486-2048), and ask how you can get in touch with a Medicare Ombudsman.
Appeals for Medicare Advantage plans
You, your doctor, or a personal representative that you appoint can request an “organizational determination” from your Medicare Advantage plan if you disagree with a coverage decision. If you are not satisfied with the organizational determination, you have 60 days to file for a reconsideration from your plan, which is the first level of appeal. Depending on the type of decision you are appealing, the process may take from 72 hours to up to 60 days. If the plan decides against you, your appeal is automatically forwarded to Level 2, review by an Independent Review Entity (IRE).
The IRE has 72 hours to decide on a coverage decision for medical treatment your doctor believes is necessary, and up to 60 days for a payment request. If you disagree with the IRE’s decision, you have 60 days to escalate your Medicare appeal to Level 3, a hearing before an administrative law judge, described below.
Medicare Prescription Drug Plans
If you believe your Medicare Prescription Drug Plan should cover a prescription medication that you need, and the plan doesn’t cover it, you can file an appeal to your plan. Either you or your doctor can file this type of Medicare appeal. For more information, see this article.
If you need help finding a Medicare health or prescription drug plan, I’m happy to assist you. To get started, simply click the Get Quotes button to schedule a phone call or to request a personalized email.