Claims and Appeals

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When do I need to file a claim?

You should only need to file a claim in very rare cases.

Medicare claims must be filed no later than 12 months (or 1 full calendar year) after the date when the services were provided. If a claim isn't filed within this time limit, Medicare can't pay its share. For example, if you see your doctor on March 22, 2016, the Medicare claim for that visit must be filed no later than March 22, 2017. Check the "Medicare Summary Notice" (MSN) you get in the mail every 3 months, or login to MyMedicare.gov to make sure claims are being filed timely. If the claims aren't being filed timely:

Contact your doctor or supplier, and ask them to file a claim.

If they don't file a claim, call 1-800-MEDICARE. Ask for the exact time limit for filing a Medicare claim for the service or supply you got. If it's close to the end of the time limit and your doctor or supplier still hasn't filed the claim, you should file the claim.

How do I file a claim?

Fill out the Patient Request for Medical Payment form:

(http://www.cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-Items/CMS012949.html )

Follow the instructions on the second page to submit the form to your carrier.

If you don't know the address for your carrier, you can:

Find it under the "Downloads" section of the MyMedicare.gov page. Select one of the links with "instructions" in the name. Look at your "Medicare Summary Notice" (MSN). To view an electronic version of your MSN, login to MyMedicare.gov.

If you want someone to be able to call 1-800-MEDICARE on your behalf or you want Medicare to give your personal information to someone other than you, you need to fill out an "Authorization to Disclose Personal Health Information”

Medicare appeal Information

An appeal is the action you can take if you disagree with coverage or a payment decision by Medicare or your Medicare plan. That decision can be made by Medicare or by the private Medicare-approved health plan that administers your Medicare Advantage (MA/MAPD) plan, prescription drug plan (PDP) or special needs plan (SNP).

When can I appeal a payment or coverage decision?
You can file an appeal if Medicare or your plan denies one of the following:

  1. Your request for a health care service, supply, item or prescription that you think you should be able to get.
  2. Your request for payment for health care service, supply, item or a prescription drug you already got.
  3. 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 an item or service you think you still need.

What happens if I decide to file an appeal?

If you decide to appeal, first 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. Medicare and all companies that provide Medicare plans are required to help you file an appeal.

The appeals process for all types of Medicare plans has five levels. At each level, a decision about your appeal is made and communicated to you in a letter. 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.

How you file an appeal depends on the type of Medicare coverage you have. But no matter what type of Medicare plan you have, at any step of the appeals process, you can—and may want to—ask your doctor, health care provider or supplier for any information that may help your case, or other help.

Medicare Plans and Appeals

Original Medicare

If you’re on Original Medicare, then every three months you’re mailed a Medicare Summary Notice, or “MSN.” An MSN shows all services or supplies that health care providers and suppliers billed to Medicare for your care during the three-month period. It shows what Medicare paid, and what you may owe the provider. You can also view your MSNs electronically on MyMedicare.gov.

Your first step is to find the MSN that shows the service or supply you’re appealing. You then have two options to file the appeal:

1. Fill out a Redetermination Request Form (PDF). Send it to the Medicare contractor at the address listed in the “Appeals Information” section of your MSN. Or, you can…

2. Follow the instructions on the back of your MSN, and send the request for an appeal without the Redetermination Request Form. You provide the same types of information as what’s asked for on the form, and send it to the Medicare contractor listed.

Generally, you get a decision from your Medicare contractor within 60 days after they get your request. The decision is called a “Medicare Redetermination Notice,” and it can come as a separate notice or as part of your MSN.

Medicare Advantage Plan (Part C)

You have the right to ask the company that administers your Medicare Advantage plan to pay for, or cover, health care services or items you believe should be covered. This request for services or supplies is called an “organization determination.” You can either ask for a determination yourself, or have your doctor or someone representing you ask for one.

Organization determinations typically take 14 days. If you or your doctor thinks your health could be harmed by waiting that long, you can ask for an “expedited” or fast determination. Then your health plan has 72 hours to give you a decision.

Your plan can approve your request, or partially or fully deny it. Your plan will send you a written notice explaining why, and give you information on how to file an appeal. This process may vary depending on your plan, so follow the instructions provided. However, regardless of your plan, you are allowed to ask for a copy of your file containing medical and other case information.

Medicare Prescription Drug Plan (Part D)

Appealing a decision for a Part D plan typically means working with your plan to get coverage for a prescription drug that you feel you need. As with a Medicare Advantage plan, this usually involves either you or your doctor (or representative) working directly with the company that administers your Part D plan.

Prescription drug coverage relates primarily to your plan’s formulary, or drug list.

Medicare Special Needs Plan (SNP)

Your Medicare SNP needs to tell you in writing how to file an appeal. After you file an appeal, the plan reviews its original decision. If your plan doesn’t decide in your favor, the appeal is reviewed by an independent organization that works for Medicare, not for the plan.

For more information, contact the Medicare helpline 24 hours a day, seven days a week at 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048. If you have questions about Medicare Made Clear, call 1-877-619-5582, TTY 711, 8 a.m. – 8 p.m. local time, seven days a week.

Important Resources

Understanding Medicare is no simple task. Here are 6 important resources you can use to get the help you need.

1. Visit Medicare.gov/find-a-plan to use the Medicare Plan Finder.

2. Look at your most recent “Medicare & You” handbook to see a listing of plans in your area. You should also review any information you get from your current plan, including the “Annual Notice of Change” letter.

3. Call 1-800-MEDICARE (1-800-633-4227), and say “Agent.” TTY users should call 1-877-486-2048. Help is available 24 hours a day, including weekends. If you need help in a language other than English or Spanish, let the customer service representative know the language.

4. Get free personalized health insurance counseling by calling your State Health Insurance Assistance Program (SHIP). Visit shiptacenter.org, or call 1-800-MEDICARE to get the phone number.

5. The Centers for Medicare & Medicaid Services (CMS) is a Federal agency within the U.S. Department of Health and Human Services. Many CMS program related forms are available in Portable Document Format (pdf) by following the link below. (http://cms.gov/Medicare/CMS-Forms/CMS-Forms/CMS-Forms-List.html)

6. Do you need Extra Help paying for Medicare prescription drug coverage? If you have limited income and resources, you may qualify for “Extra Help” to pay your prescription drug costs. Visit socialsecurity.gov/i1020 to apply online. Or, call Social Security at 1-800-772-1213 and ask for form SSA-i1020. TTY users should call 1-800-325-0778.