Medicare recipients who receive denials for their claims are permitted to appeal the denial through a three-step appeals process. At each level of your appeal, you have an opportunity to present reasons why you feel your claim should be approved. The third appeal takes place in front of an administrative judge, who will review your entire claim history and make a final decision only if your first two appeals are unsuccessful. You have 180 days from the date of your first Medicare claim denial to appeal the decision, but the sooner you file your initial appeal, the faster you will receive a decision.
Instructions
1. Review your Medicaid claim denial letter, determining the reason(s) your claim was denied. Medicare generally provides corresponding sections of your insurance policy that further explains the denial. Use a scratch piece of paper to write down each individual reason for denial and any corresponding sections of your policy quoted within the denial letter.
2. Carefully review your current Medicare plan and compare it to the reason(s) listed for your denial. If your claim is explicitly excluded from coverage under your insurance policy, you will not be able to appeal Medicare's denial and you are entirely liable for the costs of your claim. If your claim is not explicitly excluded, or your claim is explicitly covered by your plan, make a note of any applicable sections in your insurance policy that support your position that Medicare should approve your claim.
3. Obtain Form CMS-20027 (Medicare Redetermination Request Form). You can request one in person at your local Medicare office or contact your Medicare representative to have the form mailed to your home for free. You can also download and print the form directly from the Medicare website. Note that if you currently have a relative or friend handling your Medicare claims for you, you will also need to obtain or download Form CMS-1696 (Appointment of Representative) and Form CMS-20031 (Transfer of Appeal Rights), which you and the person handling your claims will need to complete and sign. This will allow your representative to act on your behalf and handle your Medicare claim denial appeal for you. Complete and submit these along with your appeal.
4. Complete Form CMS-20027, filling in your personal information, your Medicare account number and information regarding your denied claim. On Line 5, provide the reason(s) why you disagree with Medicare's claim denial, citing the sections of your insurance policy you previously compiled. If you need additional room to present your case, use another piece of paper and attach it to the back of Form CMS-20027. Sign the bottom of the form when you are finished.
5. Make a copy of your signed Form CMS-20027 and retain the copy for your personal records. Mail or fax the original signed form to the same Medicare representative who denied your claim. If you win your appeal, Medicare will pay your claim and you do not need to take any further action. If your appeal is denied, you can appeal the decision two more times using two other forms.
6. Obtain and complete Form CMS-20033 (Medicare Reconsideration Request Form) only if your first appeal is denied. You have 180 days from the date of your first regeneration appeal to file this appeal. Follow the same steps above to complete and submit the form, but submit the completed form to the Qualified Independent Contractor (QIC) assigned to your case. The Medicare representative who handled your first appeal can provide you with the QIC's contact information. If you win your appeal at this level, Medicare will pay your claim and there is nothing further for you to do. If your second appeal is denied, you can appeal one more and request an administrative hearing to argue your case.
7. Obtain and complete Form CMS-20034A/B (Request for Medicare Hearing) only if your second appeal is denied AND the total amount of your claim is at least $120. You have 60 days from the date of your second reconsideration appeal to file this appeal. Follow the same steps once more to complete and submit the form to your Medicare representative. Your representative will schedule a hearing date, which you (and your personal representative, if applicable) must attend. Bring along your copies of the original claim denial letter, your previous appeal requests, your insurance policy, medical records related to the claim and any additional documents that support your case. The judge will review your previous appeals and make a final determination. If you lose your appeal at the hearing, Medicare will not pay your claim and you have no further appeals.
