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Medicare Advantage: Denied Coverage and Appeals

If you have ever been denied coverage from your Medicare Advantage plan, it is important for you to know that you are not helpless.

Medicare Advantage

A Medicare Advantage plan is offered by a private insurer that is required to offer the same coverage as Original Medicare, but typically offers more. The extra coverage usually includes dental, vision, and drug coverage.

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Denied coverage

Recently, there have been a significant number of appeals that have been granted to those who previously received a denial from their Medicare Advantage plan. The increase in numbers has raised some flags for the National Council on Aging’s Center for Benefits Access.

Most patients who receive a denial do not appeal it. These denials are likely to cause more problems further down the path for the patients and providers. When a provider is denied payment, they are more likely to turn down other services as well.

Common Appeals

Many different types of services are denied, but where you go from there is up to you. The following list comprises some of the most common situations:

  • Your plan denied payment for medical services outside of your Medicare Advantage plan in an emergency.
  • Your plan no longer includes a service that is medically necessary.
  • Your plan did not give you a treatment in a timely manner.

What to do

If you are denied coverage from your Medicare Advantage plan, it is crucial that you thoroughly read through the denial notice. Knowing and understanding your rights is the first step in filing an appeal.

While it is not uncommon for the denial notice to be unclear or even have incorrect information listed, it is important to stay on top of it. Even if you are unsure, follow the instructions that are listed on the denial notice in order to file an appeal.

Talk to your doctor about the process and have him or her write a letter stating that the service or care is medically necessary.

Like most things, there is a timeline to properly handle your denial. Medicare Advantage beneficiaries have 60 days from the date of the denial notice to file an appeal. Following your appeal, the plan must make a decision in the following 30 days if you have not already received the service in question. If they are refusing to pay for a service that you have already received, they have 60 days to come to a decision.

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