A medical appeal process involves appealing a decision by your insurer not to cover the cost of your treatment or medication. The process is time-consuming; however, many denials are resolved through the medical appeal process. The process begins when one receives a denial through an Explanation of Benefits (EOB). An appeal is a request to an insurer to reconsider. More than 50% of appeals are successful. Some common elements cut across different health plans. There are three different levels of appeal. The first is referred to as First Level Appeal. At this level, you and your doctor contact the insurance company and request them to reconsider the denial. The doctor speaks with your insurance medical reviewer and engages in a "peer-to-peer insurance review." The point of the review is to prove that your policy covers the particular treatment and was incorrectly rejected (WebMD, 2019).
In case the medical reviewer denies the appeal, you move to the Second Level Appeal. At this level, a medical director, not involved in the initial claim decision, reviews your appeal. The point of this level of appeal is to prove that the requested treatment is within the coverage guidelines. If the appeal is denied at this level, you move to the third level, which involves an Independent External Review. At this level, an independent reviewer and a doctor with the same specialty as your doctor review your appeal (WebMD, 2019). If your appeal is denied at this level, you can find alternatives to help cover your medication or treatment through online communities dedicated to helping those whose claims have been denied. Help may be technical or financial. In case you find it difficult filing an appeal, you can find a consumer assistance program in your state. The state’s healthcare Ombudsman may also assist you in the process and can issue an appeal on your behalf.
Delegate your assignment to our experts and they will do the rest.
Filing a Medicare appeal depends on the type of plan; however, the appeal process has five different levels. Whenever an application is approved or denied, you receive a record of the same in a “Medicare Summary Notice” sent to your mail every three months. In the Medicare Summary Notice, circle the item you would like to appeal and fill the “Redetermination Request Form” with the reason you are appealing. The form can be sent to you if you call 800-MEDICARE (800-633-4227) and request the form. You can also download the form from cms.gov. Make sure you sign the form, including your Medicare number and phone number and make a copy. Send the form to a Medicare contractor and include any documentation supporting your appeal (Juvenile Diabetes Research Foundation, 2019). You can only appeal with 120 days of receiving the Medicare Summary Notice. If the first appeal is denied, you can file a second appeal with an independent contractor. A Reconsideration Request Form is used for this level and is available at cmd.gov. The second level appeal must be filed within 180 days of the first appeal denial. You can file a fast appeal by calling the Quality Improvement Organization in your state. If you are covered under Medicare Advantage, you need to follow the rules of the private insurance company covering you. Under Medicare Advantage, you may file an appeal within 60 days of receiving a denial. If you request a ‘fast decision,’ the insurer is legally required to give you feedback within 72 hours (Juvenile Diabetes Research Foundation, 2019).
Medicare Prescription Drug Plan has a different appeal process. If the plan does not pay for your medication, talk to your doctor to see if there is an alternative drug, you can take that is covered by the plan. If there is no alternative drug, request your doctor to write a detailed explanation and submit it to the Medicare drug plan. If the written request is denied, file a formal appeal (WebMD, 2019). If the appeal is denied, you can file another or a grievance by calling the Medicare telephone line. Ones all appeal options are exhausted; you can request a hearing with an Administrative Law Judge (ALJ). You can get a form for requesting a hearing from the CMS website. If the request is denied by an ALJ, ask your doctor and attorney to help you explore other legal alternatives.
References
Juvenile Diabetes Research Foundation. (2019). Denials / Appeals: What to Do When Your Insurance Company Denies You Coverage. Retrieved 13 November 2019, from https://www.jdrf.org/t1d-resources/living-with-t1d/insurance/insurance-denials-appeals/
WebMD. (2019). How to File a Medicare Appeal. Retrieved 13 November 2019, from https://www.webmd.com/health-insurance/how-to-file-a-medicare-appeal#1
