Medicare Appeals Process
Medicare can sometimes feel confusing and frustrating, especially if you disagree with Medicare’s decision to pay a claim or feel they did not pay enough on the claim. Here is a helpful guide for you on the Medicare Appeals Process.
You can first file a first-level appeal with the Medicare contractor that originally processed the claim. For example, if you have Railroad Medicare, your part B claims are processed by Palmetto GBA. Your part A claim, which includes hospital stays or being at a Skilled Nursing Facility or any other facility or claims for medical equipment and supplies, are processed by your local Medicare Administrative Contractors. When you receive your Medicare Summary Notice (MSN), the name and address of the processor are on that notice.
The first level of appeal is called the redetermination and must be filed within 120 days from the date you receive notification of the first determination. Generally, the presumed receipt date is five days after the date listed on the notice unless you can prove with evidence that the determination, decision, or notice was not received during that time. You can supply additional documentation to support your request at this level of the appeal.
Suppose your request is denied and you would like to continue with your request or feel dissatisfied with the redetermination decision. In that case, you can file a second-level appeal with a Qualified Independent Contractor. Their address is on the redetermination letter that shows why your initial claim was denied. You will have 180 days to file the QIC request.
You will have an Administrative Law Judge presiding over your appeal during the third appeal process. You only have 60 days to file this appeal, and the amount in controversy must exceed $180 for the year 2022. You cannot submit new documentation at this time unless you can prove good reason it was not initially with your documents during the first two appeals.
You may file up to 5 times. Then, during the fifth level of appeal, it will go to the U.S. District Courts. At this level, the minimum amount in controversy is $1760 for 2022.
What to Include in an Appeal Request?
Every appeal requires the same basic information:
- The Beneficiary name
- Medicare number
- The specific service or items for which the redetermination is being requested
- The specific date of service
- Name of the person requesting the appeal
- Why you disagree with the decision on the claim
- Documentation to support your claim
You must submit the requests in writing. You cannot email appeals. Your MSN includes instructions for filing your appeal in writing. If you have further questions, call our Beneficiary Contact Center at 1-800-833-4455. You may also use the free internet portal MyRRMed to access claim status. You can visit the website by typing in www.PalmettoGBA.com/MyRRMed.
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