Claim denials can be frustrating and even a threat to the quality of care a patient requires. Medicare claims can be denied when the provider does not include or even excludes information needed to process a claim, when the provider does not explain the medical necessity of the service, and when medical services were received by a patient from a provider that is not enrolled in the Medicare program. When a claim is denied, a Medicare recipient has the right to appeal the decision.
If a Medicare patient is denied a claim where payment is refused for a necessary item (medical equipment) or service, then an A or B appeal can be filed. An A or B appeal can be a lengthy process with five stages-redetermination, reconsideration, Administrative Law Judge, Medicare Appeals Council, and judicial review in federal court.
Also known as Part C, a Medicare advantage claim can be denied if Medicare stops payment, does not allow, or terminates a service that the patient assumes should be paid. Because each Medicare C program has its own appeal process, the patient must coordinate with the federal Medicare program as well as the private insurance company that manages the Medicare Part C program.
If a patient believes that Medicare should provide coverage for, or reimburse the patient for prescription drugs, then a Medicare Part D appeal is filed. Because many different companies manage Part D plans, each plan must provide,in writing, how to petition for an appeal.
Where can I find the forms for appeal if Medicare denies my claim?
All forms can be downloaded from www.Medicare.gov on the internet. Assistance in filling out the forms is available by calling a toll free number provided on the website.