Beginner’s Guide to the Medicare Appeals Process

The Medicare appeals process is a procedure for enrollees who were denied coverage for specific prescriptions or services. While it can be stressful to learn that your medication is not covered by the program, there are ways you can potentially overturn this decision. The U.S. Department of Health and Human Services (DHHS) oversees the Office of Medicare Hearings and Appeals (OMHA). This office is responsible for hearing and responding to appeals requests.

If you are beginning the Medicare appeal process, you may be overwhelmed by the steps you must complete. However, it is simple to file your appeal once you understand what is expected of you. Make sure you understand the various Medicare appeal levels so you know which step applies to your situation.

Reasons to Begin the Medicare Appeal Process

There are various situations that could require you to submit a Medicare appeal form for reconsideration. Examples of situations where you could appeal include:

• You are denied Medicare coverage for a prescription drug, service or item that you believe you should be able to receive through the program.
• You already obtained a prescription drug, service or item and were denied payment.
• You wish to adjust the amount you are responsible for paying for a prescription drug, service or item.
• Your plan refuses to continue paying for a prescription drug, service or item you believe you still require.

How to File a Medicare Appeals Request

You can begin the Medicare appeal process using different strategies. However, keep in mind that the exact steps you need to follow to submit your request depends on what you are appealing. In fact, the specific Medicare claim appeal form and supplementary information you need to submit depends on if you are appealing decisions relating to:

• Original Medicare.
• Medicare health plans.
• Prescription drug coverage.
• Special Needs Plans.

Whether you need to obtain a Medicare appeal form PDF or you need to know how to contact your provider, this information is available online. However, keep in mind that you may also be able to visit your closest Social Security office and file your request in person.

How many levels are there in the Medicare appeals process?

If you consult a Medicare appeals process flow chart, you will see there are five appeals levels you can use. You must start on the lowest level of appeals with your first request. You can only progress to a higher appeals level if your previous appeal was denied. If you have a Medicare denied claim, your appeals levels are as follows:

• Level One. Redetermination by a Medicare Administrative Coordinator (MAC)
• Level Two. Reconsideration by a Qualified Independent Contractor (QIC)
• Level Three. Decision by the OMHA
• Level Four. Review by the Medicare Appeals Council
• Level Five. Judicial Review in Federal District Court

How to Expedite the Medicare Appeal Process

In certain circumstances, you can request to expedite the Medicare appeals process. However, you will only be able to use this option if your life, health or functionality can be damaged if you wait the standard 30 days it takes for you to receive a response. If you expedite your request, you can receive a response in as little as 72 hours from the date and time you filed your appeal.