Medicare Services Appeal

A Medicare Services Appeal is a formal process in which a beneficiary or their representative challenges a decision made by Medicare regarding coverage or payment for a health care service. The appeals process is available to all Medicare beneficiaries and is intended to provide a fair and impartial review of decisions made by Medicare. A Medicare appeal is an action you can take if you disagree with a coverage or payment decision made by your Medicare health plan or your Medicare prescription drug plan. You can appeal this decision directly to Medicare if your plan denies one of these:

• Your request for a health care service, supply, item, or prescription drug that you think you should be able to get.
• Your request for payment for a health care service, supply, item, or prescription drug you already have
• Your request to change the amount you must pay for a health care service, supply, item, or prescription drug

1. Redetermination: The first level of appeal is a request for redetermination, which is reviewed by the Medicare Administrative Contractor (MAC) that issued the initial decision. This must be done within 120 days of the initial decision.

2. Reconsideration: If the redetermination decision is unfavorable, the beneficiary can request a reconsideration by a qualified independent contractor (QIC). This must be done within 180 days of the redetermination decision.

3. Administrative Law Judge (ALJ) Hearing: If the reconsideration decision is unfavorable, the beneficiary can request an ALJ hearing. This is conducted by an independent hearing officer within the Office of Medicare Hearings and Appeals. This must be done within 60 days of the reconsideration decision.

4. Medicare Appeals Council Review: If the ALJ decision is unfavorable, the beneficiary can request a review by the Medicare Appeals Council. This must be done within 60 days of the ALJ decision.

5. Judicial Review: If the Medicare Appeals Council decision is unfavorable, the beneficiary can request a judicial review in federal district court. This must be done within 60 days of the Medicare Appeals Council's decision.

You can also appeal if Medicare or your Medicare Advantage plan stops providing or paying for all or part of a service, supply, item, or prescription drug you think you still need for treatment.

MedHelpCenter.us recommends that you call the Senior Health Insurance Agency at 813-592-8568 for further explanation.