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Appealing a Medicare Claim with Original Medicare (specific to California):

What if you have original Medicare and would like to appeal a claim decision with either original Medicare or your Medicare Supplement Insurance Plan? Since Medicare Supplement Plans only cover the gaps in original Medicare, if Medicare denies your claim, the Supplement Plan will as well.

There are five levels to appealing a Medicare Claim if you have Original Medicare (Medicare Parts A and B, with or without a Medigap/Medicare Supplement Insurance Policy).

Appealing a Medicare Claim: Level 1 Medicare Appeal is the Re-determination by the Company that handles claims for Medicare

  • Review your Medicare Summary Notice (MSN) to see what your services and supplies were billed to Medicare during a 3 month period. If you disagree you can file a claim with the company that handles claims for Medicare. This document contains information not only about what Medicare paid, and what you owe the provider, but also contains information about your appeal rights. There are 3 ways to file a Level 1 appeal:
  • Fill out a form called the “Redetermination Request Form” and send it to the Medicare provider at the address listed on your Medicare Summary Notice (MSN). Include a copy of the MSN and circle the items you disagree with. On a separate sheet of paper, explain why you disagree with the decision, and include the following:
    • Your Medicare Number
    • Your name, address, and phone number
    • Your signature
    • Any information that you can get from your provider that may help your case

There are 3 ways to file an appeal:

  1. Fill out a “Redetermination Request Form” and send it to the Medicare contractor at the address listed on the MSN. OR:
  2. Follow the instructions on the back of the MSN. You must send your request for re-determination to the company that handles claims for Medicare (their address is listed in the “Appeals Information” section of the MSN.)
    • Circle the item(s) and/or services you disagree with on the MSN.
    • Explain in writing why you disagree with the decision or write it on a separate piece of paper, along with your Medicare number, and attach it to the MSN.
    • Include your name, address, phone number, and Medicare number on the MSN and sign it.
    • Include any other information you have about your appeal with the MSN. Ask your doctor, other health care provider, or supplier for any information that may help your case. OR
    • Send a written request to the company that handles the claims for Medicare.       You will find their address listed on your MSN in the “Appeals section”.   Include all of the information listed above but instead of circling the items you disagree with, describe the specific item(s) and/or service(s) for which you're requesting a re-determination and the specific date(s) of service, and include an explanation of why you don't agree with the initial determination.
    • Don’t forget to sign the letter, and if you have an appointed representative (for example, your doctor) then that person must sign as well.

Don’t forget to write your Medicare Claim number on every piece of paper or document that you submit. And, it is very important to keep copies of EVERYTHING that you submit as part of your appeal.

  • Write your Medicare number on all documents you submit with your appeal request.
  • Keep a copy of everything you send to Medicare as part of your appeal.

If you forget to submit something, you can do so later, but it will delay the process.

Typically you will hear back within 60 days from the day you get your request. If you disagree with their decision, you can move your appeal to Level 2.

Appealing a Medicare Claim: Level 2 Medicare Appeal is the Reconsideration by a Qualified Independent Contractor or QIC

  • You can either fill out a Medicare Reconsideration request form, your send a written request that includes your name and Medicare number, the specific items/services you are requesting a review of and the dates of service. You should also include the name of the company that made the determination in Level 1, an explanation of why you disagree, and your signature. If you have appointed a representative, include the name and signature of that person as well
  • Send your form or written request to the QIC, whose address will e listed on your redetermination notice. You should also include any other information that will help our case.
  • You will get a written response in about 60 days after the QIC gets your appeal request. If you disagree with the decision, or do not get a timely request, you can move your appeal to level 2. You have 60 days after you get the Medicare Reconsideration Notice to move to Level 3.

Appealing a Medicare Claim: Level 3 Medicare Appeal is a Hearing before an Administrative law Judge or ALJ

  • At this level, if you want your doctor to file on your behalf, you will need to submit an appointment of representative form.
  • The ALJ allows you to present your appeal to an independent person who will listen to our testimony before making an impartial decision. You can also request the ALJ to do so without a hearing if you’d like.
  • Your case must be for a minimum amount of $150 in 2016.
  • If you have original Medicare, you should follow the instructions you received in the Medicare Reconsideration Notice that you got in Level 2
  • You can fill out a request for Medicare Hearing by an Administrative law Judge form, or you can submit a written request with your name, address, and Medicare Claim number, the appeal number, the dates of service and items you are appealing, along with an explanation of why you disagree and any other information that may help our case.
  • In most cases you’ll get your decision within 90 days. If it takes longer than that, or if you disagree, you can move your case to level 4.   You will have 60 days to do so.

Appealing a Medicare Claim: Level 4 Medicare Appeal is a Review by the Medicare Appeals Council

  • If you want your doctor to file a level four appeal on your behalf you’ll need to submit an Appointment of Representative form at this level.
  • You’ll need to follow the directions in the ALJ’s hearing decision that you got in Level 3. You can either fill out the form (Request for Review of an ALJ Medicare Decision/Dismissal form) or you can submit a written request that includes the information that is in the form:
  • Your name, representative’s name (if any) and your Medicare Claim Number
  • The specific items/services and dates of service that you are appealing
  • A statement identifying the parts of the decision that you disagree with and why you disagree
  • The date of the ALJ decision or if you are asking that your case be moved to the Appeals Council because the ALJ hasn’t issued a timely decision, include the hearing office where the request is pending.
  • Your signature, or if you have a representative, that person’s signature.
  • Level four can take 90 days to process. If they take longer, or if you disagree with Level 4 you have 60 days to request Level 5

Appealing a Medicare Claim: Level 5 Medicare Appeal is a Judicial Review by a Federal District Court

  • Your claim must be at least $1500 in 2016 to go to level 5.You should follow the instructions in the letter you got in level 4 to move to this next level.

You also have the right to FAST appeals, and we will discuss this in a different section. I’ll post the link when the article is finished.   If you have any questions, feel free to call us at 866-445-6683 or contact us HERE through our Contact us page.

For more information about the appeals process, go to www.Medicare.gov. For assistance with other Medicare Related issues, feel free to give us a call at 866-45-6683 or contact us using our form.

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