Chances are, that at some point, you will experience Medicare denial for a health service or item. Some HMO and PPO plans even hand out payment and bonuses to professionals to limit your access to specialists and major medical equipment.

• Read your notices carefully and completely. They will contain information on how to begin your appeal process. If you are one of our clients, we will be glad to assist along the entire process.
• Appeal the decision right away! Don’t let a lack of motivation cost you money. Get the appeal process started right away.
• Ask your doctor for help. Have your doctor write something to help your case. The appeal has a higher chance of working with the written support of your doctor.

There are differing levels of appeal

Appealing Medicare denial for service is not a straightforward process. There are multiple levels of appeal along the way and you must continue with the appeal process with each successful appeal. Each level of appeal also has its own unique time frame that you should respond to promptly.

Medicare denial starts when you receive a Medicare Summary Notice outlining the decision and the method of appeal. If you are on a Medicare Advantage plan you will receive an Explanation of Benefits in place of a Medicare Summary Notice. Each document would explain the amount the insurance will pay and how much the provider billed, leaving you with a remaining balance. If you are concerned with or do not understand the reason of Medicare denial, you should call your Medicare Advantage Plan to learn more.

The method of appeal usually contained within the document (either the Medicare Summary Notice or Explanation of Benefits) outlines the process to follow. If filling out the paperwork is confusing to you feel free to reach out to Newnan Medicare for assistance. Fill out and send the paperwork to the Medicare Administrative Contractor. Generally, you have 120 days from the Medicare denial to begin the appeal process. Successful appeals return the money you paid for the service or item to your wallet!

For a more detailed write-up, look here.

How to appeal a Medicare Advantage Plan’s Medicare denial of service

The type of document you receive from your plan outlining the denial will depend on if you have already received the service or not. In either case, the method of appeal will be on the document you receive. The only difference will be to time you have to wait on the appeal:

• If you have already received the item or service, your plan will make its decision within 60 days.
• If you are requesting a service and it is being denied, your plan will make its decision within 30 days.

Additionally, urgent matters can be expedited. The plan must respond within 72 hours.

If your Medicare appeal is initially denied, you may continue to request an appeal. Instructions for continuing the appeal will always be contained within the notice of Medicare denial of appeal. However, in the event your appeal reaches the Office of Medicare Hearings and Appeals, it may be a good idea to contact a lawyer for assistance.

Incidentally, there are additional ways in which Newnan Medicare can help with this process, if we are your agent of record. Contact us to learn more.