Final Medicare Answer is NO? Maybe not.
If I am denied coverage from Medicare for a service, supply or prescription drug, do I have any rights to appeal their decision? Please explain how to go about this.
You should make a practice of reviewing the Medicare Summary Notice (MSN) you receive in the mail. This notice provides details on services and supplies billed to Medicare during the prior 3 months and will indicate if Medicare has fully or partially denied any of your medical claims. If will also provide information about your appeal rights.
You can file an appeal if Medicare denies your request for one of the following:
· a health care service, supply, item, or prescription drug that you think you should be able to get
· payment for a health care service, supply, item, or prescription drug you already got
· a change in the amount you must pay for a health care service, supply, item or prescription drug.
You can also appeal if Medicare stops providing or paying for all or part of a service, supply, item, or prescription drug you think you still need.
The appeals process has five levels. If your appeal is turned down at any level, you have the option of taking it to the next level. You will be given instructions on how to move to the next level if your initial appeal is denied.
To file an appeal, you should circle the item you are appealing on your MSN and clearly explain why you think Medicare’s decision is wrong. You can write on the MSN or attach a separate page.
In general, your request should include:
· Your name, address, and the Medicare number shown on your Medicare card
· Description of the items or services for which you’re requesting a reconsideration, including the dates of service and the reason for your appeal
· The name of your representative, if you have one, and proof of representation
Include any information or documentation that supports your request, including information from your doctor or other providers.
You can also use the Medicare Redetermination Form (20027) for this step. You can download this form from Medicare.gov or call 800-MEDICARE (800-633-4227) to request a copy by mail.
You must file your appeal within 120 days of the date you receive the MSN and you can expect a decision in most cases within 60 days.
You also have the right to a fast appeal if you think your Medicare-covered services are ending too soon. This includes services you get from a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility or hospice. Your provider will give you a written notice before your services end that tells you how to ask for a fast appeal. If you're not given this notice, ask for it.
Insurance rules and regulations can be confusing. If you have questions concerning life, health, Medicare Advantage Plans or Medicare Supplement insurance, please contact me at 440-255-5700 or Lmutsko@mutskoinsurance.com.
Laura Mutsko is a licensed insurance broker offering a complete line of health and life insurance products, including Individual, Group and Family Health, Medicare Advantage Plans, Medicare Supplement Plans, Medicare Part D Prescription Coverage, Vision, Dental and Life Insurance. Mutsko Insurance Services, LLC is located at 6966 Spinach Drive in Mentor, Ohio.