Claims & Appeals

Claims

Most Medicare recipients will never need to file a claim. In most cases, your doctor or healthcare provider will file claims for you. If you do need to file a claim, here’s what you should know.

When Do I Need to File a Claim?

Medicare claims must be filed no later than 12 months after the date when the services were provided. Medicare can’t pay its share if claims are not filed within 12 months. For example, if you see your doctor on February 12, 2020, the Medicare claim for that visit must be filed no later than February 12, 2021. You should receive a Medicare Summary Notice (MSN) in the mail every 3 months that lists all services performed by your doctor. MSNs will also list what Medicare has paid and the amount you may owe the provider. Additionally, you can check MyMedicare.gov to make sure claims are being filed timely. If they’re not, contact your doctor or healthcare provider and ask them to file the claim.

If they still don’t file the claim, call 1-800-MEDICARE (1-800-633-4227) and ask for the exact time limit left for filing the claim. If it’s close to the end of the time limit and your doctor still hasn’t filed the claim, you should file it yourself.

If you go to a doctor that has not accepted Medicare assignment, you might have to file a claim yourself. However, Medicare is not guaranteed to pay any of the services rendered by a doctor who has not accepted Medicare assignment, and you may have to pay the full cost at the time of service.

How Do I File a Claim?

Fill out the Patient Request for Medical Payment form and follow these instructions according to the type of claim you’re filing:

• Claims for Part B services
• Claims for durable medical equipment (DME)
• Claims for shipboard services (medical services received aboard a ship)
• Claims for services received in Canada or Mexico
• Claims for services you received in a foreign hospital

What Do I Submit with The Claim?

Once you’ve followed the instructions listed above, gather the following items to submit along with your claim:

• The completed Patient Request for Medical Payment form
• The itemized bill from your doctor
• A letter explaining your reason for submitting the claim (for example: if your doctor has failed to file the claim in a timely manner or they do not accept Medicare assignment)
• Any other documents that may be related to your claim

Where Do I Send The Claim?

You will find the address to which you send your claim in each packet of instructions located in the “How do I file a claim?” section above. You can also find information on where to send your claim in your Medicare Summary Notice (MSN).

How Do I Check The Status of My Claim?

You can check the status of your claim in several ways:

• Visit MyMedicare.gov and log into your account to access up-to-date information about your Part A and Part B claims. You will be able to see a claim within 24 hours of Medicare processing it.
• Check your Medicare Summary Notice (MSN) which you should receive in the mail every 3 months. The MSN will detail all of your covered Part A and Part B services or supplies billed to Medicare, what Medicare paid, and the maximum amount you may owe the provider.
• Use the Blue Button feature on MyMedicare.gov to download and save information about your Part A and Part B claims.

Appeals

If you disagree with a coverage or a payment decision by Medicare or your Medicare plan, you have the option to file an appeal.  The decision to deny coverage or payment may be made by Medicare, your private Medicare Advantage plan (MA/MAPD), prescription drug plan (PDP), or special needs plan (SPN).

What’s an Appeal?

You can appeal the decision if Medicare or your plan denies one of these:

• Your request for coverage of a service, supply, item, or prescription drug you think you should be able to receive
• Your request for payment for a service, supply, item, or prescription drug you’ve already received
• Your request to change the amount you must pay for a service, supply, item, or prescription drug

If You Decide to Appeal

If you’d like to file an appeal, begin by asking your doctor for any information that may help your case. Then, refer to your Medicare Summary Notice (MSN). Medicare will mail you an MSN every 3 months that will list all of the services and supplies you’ve received, what Medicare has paid, and what you may owe the provider. The MSN will also show if Medicare has denied all or part of your medical claim. You must file an appeal within 120 days of receiving the MSN containing the claim you’d like to appeal.

Note: Each document you send for an appeal should include your Medicare Number and the name of your representative, should you choose to appoint one. It would be wise to keep a copy of every document for your own records. Alternatively, you can request a copy of your case from your plan at any time during the appeals process, but your plan may charge you for this copy.

If you need help or more information during any step of the appeals process, you can contact your State Health Insurance Assistance Program (SHIP) or call 1-800-MEDICARE. TTY users call 1-877-486-2048.

Appointing a Representative

If you would like help filing your appeal, you may appoint a representative to help with the process. Your representative can be a family member, friend, attorney, doctor, or someone else you trust who will act on your behalf during the process. You should include the name of the representative on any forms you submit for your appeal. You can appoint a representative in one of two ways:

1. Fill out an “Appointment of Representative” form
2. Submit a written request for your appeal with the following information:
   1. Your name, address, phone number, and Medicare Number
   2. A statement appointing someone as your representative
   3. The name, address, and phone number of your representative
   4. The professional status of your representative
   5. A statement authorizing the release of your personal and identifiable health information to your representative
   6. A statement explaining why you’re being represented and to what extent
   7. Your signature and the date you signed the request
   8. Your representative’s signature and the date they signed the request

Appeals for Original Medicare

The appeals process for Original Medicare has five levels. At each of the five levels, you will be given instructions on how to move to the next level if your appeal is denied. The five levels of appeal for Original Medicare are the following:

1. Redetermination by the company that handles claims for Medicare
2. Reconsideration by a Qualified Independent Contractor
3. Hearing before an Administrative Law Judge
4. Review by the Medicare Appeals Council
5. Judicial review by a federal district court

Level 1: Redetermination by The Company that Handles Claims for Medicare

For the first level of appeals, begin by referring to your Medicare Summary Notice (MSN). The MSN will show you if Medicare has fully or partially denied your medical claim and provide you with information you’ll need to file your appeal. There are three ways to file an appeal in Level 1:

1. Fill out a “Redetermination Request” form and send it to the Medicare address listed on your MSN
2. Follow the instructions for sending an appeal:
   1. Circle the services or items you disagree with on the MSN
   2. Explain in writing why you disagree with the decision
   3. Include your name, address, phone number, and Medicare Number on the MSN
   4. Sign the MSN
   5. Include any other information in the MSN that may help your appeal, including information provided by your doctor or healthcare provider
3. Send it to the company that handles claims for Medicare by locating their address on the MSN. Your request must include:
   1. Your name and Medicare Number
   2. The specific service or item for which you’re requesting redetermination
   3. Specific dates of service

If your appeal is denied, it will be sent to a Qualified Independent Contractor (QIC).

Level 2: Reconsideration by a Qualified Independent Contractor

The Qualified Independent Contractor (QIC) is someone who did not take part in your Level 1 appeal. They will review your request for reconsideration to make a decision. There are two ways to file an appeal in Level 2:

1. Fill out a “Medicare Reconsideration Request” form 
2. Submit a written request to the QIC that includes:
   1. Your name and Medicare Number
   2. The specific services or items for which you’re requesting a reconsideration
   3. The specific dates of service
   4. The name of the company that made the redetermination (This is the company that handles claims for Medicare. You can find this information in your MSN.)
   5. An explanation of why you disagree with the redetermination decision
   6. Your signature
   7. Any other information that may help your appeal, including information provided by your doctor or healthcare provider

If you disagree with the decision made in Level 2, you have 60 days after you get the “Medicare Reconsideration Notice” to request an Administrative Law Judge (ALJ) hearing.

Level 3: Hearing before an Administrative Law Judge

A hearing before an Administrative Law Judge (ALJ) will allow you to present your appeal to a judge over telephone, video-teleconference, or even in person. The judge will then make a new and impartial decision about your case. You can also request that the judge make a decision on your appeal without a hearing. In order to receive an ALJ hearing, your claim must meet exceed a certain amount. 

If you have Original Medicare, you can request a hearing in one of these ways:

1. Fill out a “Request for Medicare Hearing by an Administrative Law Judge” form
2. Submit a written request to the Office of Medicare Hearings and Appeals (OMHA) including the following information:
   1. Your name, address, and Medicare Number
   2. The appeal number included on the QIC reconsideration notice
   3. The specific dates of service for services or items you’re appealing (See your MSN or reconsideration notice for this information.)
   4. An explanation of why you disagree with the reconsideration decision being appealed
   5. Any information that may help your case, including information provided by your doctor or healthcare provider

For more information about the ALJ hearing process, you can visit the OMHA website.

Level 4: Review by the Medicare Appeals Council

To request a review by the Medicare Appeals Council (Appeals Council), follow the directions in the ALJ’s hearing decision you received in Level 3, and then send your request to the address listed in the ALJ’s hearing decision. You can file an Appeals Council request in one of two ways:

1. Fill out a “Request for Review of an Administrative Law Judge (ALJ) Medicare Decision/Dismissal” form
2. Submit a written request to the Appeals Council with the following information:
   1. Your name, address, and Medicare Number (If you have a representative, include their name)
   2. The specific service or items you’re appealing along with specific dates of service (See your MSN or ALJ hearing decision for this information)
   3. A statement identifying the parts of the ALJ’s decision with which you disagree
   4. An explanation of why you disagree with the ALJ’s decision
   5. The date of the ALJ decision
   6. Your signature (If you’ve appointed a representative, include their signature)
   7. If you’re requesting that your case be moved from the ALJ to the Appeals Council because the ALJ hasn’t issued a timely decision, include the hearing office in which the request for hearing is pending

Level 5: Federal District Court Judicial Review

Your claim must meet a minimum dollar amount in order to receive a judicial review in federal district court. You may be able to combine claims to meet the minimum dollar amount. Follow the directions in the Medicare Appeals Council’s decision letter you received in level 4 to file your final appeal.

Appeals for Other Medicare Health Plans

If you have a Medicare Advantage or other Medicare health plan and think items or services should be covered, provided, or continued, you can ask for your plan to provide or pay for them. This is called an “organization determination.” You, your representative, or your doctor can ask your plan to make sure the services or items are covered before treatment or after if payment is denied. Search here to get contact information for your plan.

If you need treatment sooner than the standard 14-day waiting period, you can ask your plan for a fast decision. They must provide you with a decision within 72 hours if you or your doctor tells your plan that waiting for a standard decision may jeopardize your life, health, or your ability to regain maximum function.

If your plan fully or partially denies your request to cover the specified services or items, you’ll receive a notice explaining why they made their decision along with instructions on how to appeal the decision. There are 5 levels to the appeals process for non-Original Medicare health plans:

1. Reconsideration from your plan
2. Review by an Independent Review Entity
3. Hearing before an Administrative Law Judge
4. Review by the Medicare Appeals Council
5. Judicial review by a federal district court

Level 1: Reconsideration From Your Plan

If you disagree with the decision of the organization determination, you can ask for a reconsideration within 60 days of the date of the organization determination. If you have yet to receive the service, your doctor can request a reconsideration on your behalf.

You can file a standard written reconsideration unless your plan allows you to file by phone, fax, or email. Get your plan’s contact information by searching here. The following information must be included in your reconsideration request: Your name, address, and Medicare Number (If you’ve appointed a representative, include the name of your representative and proof of representation.)

• The services or items for which you’re requesting a reconsideration
• The dates of service
• The reason why you’re appealing
• Include any other information that may help your case, including information given to you by your doctor or healthcare provider

If your reconsideration is denied, you can file an appeal with an Independent Review Entity.

Level 2: Independent Review Entity

If your plan denies your reconsideration, they must send you a notice that gives you specific reason(s) for full or partial denial. You may send this information to an Independent Review Entity (IRE), but you must send it within 10 days of receiving the notice. The address to the IRE will be located on the notice. The standard time for a response from an IRE is 30 days. If your appeal is denied by an IRE, you can request a hearing before an Administrative Law Judge.

Level 3: Hearing Before Administrative Law Judge

A hearing before an Administrative Law Judge (ALJ) will allow you to present your appeal to a judge over telephone, video-teleconference, or even in person. The judge will then make a new and impartial decision about your case. You can also request that the judge make a decision on your appeal without a hearing. In order to receive an ALJ hearing, your claim must meet a certain amount. 

If you have a Medicare Advantage plan, other Medicare health plan, or a Medicare Prescription Drug Plan, you can request a hearing with an ALJ in one of these ways:

1. Fill out a “Request for Medicare Hearing by an Administrative Law Judge” form
2. Submit a written request to the OMHA office that includes the following information:
   1. Your name, address, and Medicare Number (If you’ve appointed a representative, include their name and address)
   2. The appeal number included in the reconsideration notice
   3. The dates of service for the services or items you’re appealing (See your MSN for this information.)
   4. An explanation of why you disagree with the reconsideration decision being appealed
   5. Include any other information that may help your case, including information given to you by your doctor

If the ALJ denies your appeal, you can bring your appeal before the Medicare Appeals Council.

Level 4: Review by Medicare Appeals Council

If you would like to appeal the decision made at Level 3, you can request that the Medicare Appeals Council (Appeals Council) review your case and make a decision. To do this, follow the directions listed on the ALJ’s hearing decision provided to you at Level 3. You can file a request for an Appeals Council in two ways:

1. Fill out a “Request for Review of an Administrative Law Judge (ALJ) Medicare Decision/Dismissal” form
2. Submit a written request that includes the following information:
   1. Your name and Medicare Number (If you’ve appointed a representative, include their name)
   2. The specific item or service and specific dates of service you’re appealing (See your MSN for this information)
   3. A statement identifying the parts of the ALJ’s hearing you disagree with and why
   4. The date of the ALJ decision
   5. Your signature (If you’ve appointed a representative, include their signature)
   6. If you’re requesting your case be moved from the ALJ to Appeals Council because the ALJ has not made a timely decision, include the hearing office in which the request for a hearing is pending

If the Appeals Council denies your appeal, you can bring your appeal before a federal district court.

Level 5: Federal District Court Judicial Review

Your claim must meet a minimum dollar amount in order to receive a judicial review in federal district court. You may be able to combine claims to meet the minimum dollar amount. Follow the directions in the Medicare Appeals Council’s decision letter you received in level 4 to file your final appeal.

Appeals for Medicare Prescription Drug Coverage

If you think your plan should cover, provide, or continue to pay for a drug, you have the right to ask your plan to do so. If your plan denies coverage of a drug, you can request an appeal. Get your plan’s contact information by searching here.

What if My Plan Won’t Cover a Drug I Think I Need?

1. Talk to your prescriber and ask:
   1. Whether the plan has special coverage rules
   2. Whether there are generic, over-the-counter, or less expensive name-brand drugs that work as well as the drug initially prescribed
2. Get a written explanation from your Medicare drug plan (called a coverage determination). This is a decision made by your Medicare drug plan including:
   1. Whether a certain drug is covered
   2. Whether you have met the requirements to get a requested drug
   3. How much you pay for the drug
   4. Whether to make an exception to a plan rule if you request it
3. Ask for an exception if:
   1. You or your prescriber believes you need a drug that isn’t on your plan’s formulary (list of covered drugs)
   2. You or your prescriber believes that a coverage rule (like prior authorization) should be waived
   3. You think you should pay less for a higher tier drug, because you or your prescriber believes you can’t take any of the lower-tier drugs

If you’re requesting an exception, your prescriber must provide a statement explaining the medical reason(s) why the exception should be approved.

If you’re requesting coverage for prescription drugs you haven’t received yet, you or your prescriber can make a standard request by phone or in writing. If you’re asking for reimbursement for a drug you’ve already bought, your prescriber must make a standard request in writing. To ask your plan for coverage determination, you can do one of the following:

• Call your plan
• Write your plan a letter
• Send them a completed “Model Coverage Determination Request” form

Your plan has 72 hours to notify you of its decision once it has received your standard request. If you need an expedited request, you or your prescriber can request one if both of these apply:

• You haven’t gotten the prescription
• Your prescriber tells your plan that waiting for a standard decision may seriously jeopardize your life, health, or ability to regain maximum function.

Your plan has 24 hours to notify you of its decision once you or your prescriber has made an expedited request.

Making a Special Needs Plan Coverage Decision Appeal

If you need to file an appeal for a Medicare Special Needs Plan (SNP), your plan must give you written instructions on how to appeal. The plan will review its original decision after you’ve filed the appeal. If your plan doesn’t decide in your favor, an independent organization (that works for Medicare, not the plan) will review the appeal.