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Filing an Appeal with Medicare



What happen if Medicare denies a claim? You file an APPEAL.


How do I file an appeal? What's an appeal?


An appeal is the action you take if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare Prescription Drug Plan.


You can appeal if Medicare or your plan denies one of these:


• Your request for a health care service, supply, item, or prescription drug that you think you should be able to get


• Your request for payment for a health care service, supply, item, or prescription drug you already got


• Your request to change the amount you must pay for a health care service, supply, item or prescription drug.


You can also appeal if Medicare or your plan stops providing or paying for all or part of a service, supply, item, or prescription drug you think you still need.


If you have a Medicare Medical Savings Account (MSA) Plan, you may appeal if you've met your deductible or you believe a service or item should count toward your deductible.


If you decide to appeal, ask your doctor, health care provider, or supplier for any information that may help your case. See your plan materials or contact your plan for details about your appeal rights.


Generally, you can find your plan's contact information on your plan membership card. Or, you can get your plan's contact information from a General Search or search by plan name utilizing a internet search like Google.com or Bing.com


The appeals process has 5 levels. If you disagree with the decision made at any level of the process, you can generally go to the next level. At each level, you'll be given instructions in the decision letter on how to move to the next level of appeal. These are the 5 levels listed below and you must go through them in order.


Level 1: Redetermination by the company that handles claims for Medicare


Level 2: Reconsideration by a Qualified Independent Contractor (QIC)


Level 3: Hearing before an Administrative Law Judge (ALJ)


Level 4: Review by the Medicare Appeals Council (Appeals Council)


Level 5: Judicial review by a federal district court

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