Medicare generally pays for most medical services that a recipient needs. The process is smooth the majority of the time. However, the process does not go as smoothly for some. Someone may find that a treatment or medication is denied. If you receive a notice from Medicare denying services, you can dispute this Medicare denial of benefits. It is critical to have all of the supporting documents that will support your claim for approval of services.
If a person decides to dispute a medicare denial of benefits, the denied party must request that a competent independent contractor reevaluate Medicare’s decision. The request for a reexamination must be made within 180 days from the notice of denial of Medicare benefits.
After reviewing the case, the independent contractor will send the Medicare beneficiary a decision. If the decision is favorable, you can request a hearing before an Administrative Law Judge. The amount of the denial must exceed $130 before this request can be granted.
The Third Step Is The Administrative Law Judge Hearing
After appearing before the judge, if the decision is not favorable, the denied party still has another option. You can request that the case go before the Medicare Appeals Council. By the time the case reaches this point, it is unlikely that the decision will be reversed. If the amount is $1,200 or less, the Appeals Council will render the final decision. In cases where the amount exceeds $1,200, the denied party can ask for a judicial review.
In conclusion, Medicare beneficiaries have a process they can go through to appeal denials. This contributes to the process being fair, and the original decision makers being accountable to a higher authority. By the time the case has gone all the way through the process, the evidence has been examined thoroughly, and the chances of a reversal become slim.