Sometimes seniors are denied claims and they think there is nothing they can do and they just accept it. However, a denied or partially paid claim can be appealed and nearly half of the appeals are successful and worth the effort…might as well give it a try.
When a Medicare claim is denied or approved for less that full amount, you have 120 days to request a “redetermination” of the decision. The proper form to request is called Medicare Redetermination Request Form (Form CMS-20027) which can be downloaded at www.CMS.HHS.gov or you can call (866) 544-8825.
The written claim denial that you receive includes instructions on where and how to submit the redetermination form. The claim denial should include an explanation why your claim was denied or only offered partial payment. You need to object the explanation in order to be successful with the appeal. You can ask your doctor to write a letter responding to the points raised in the denial and explain why your health care is necessary. You include a copy of this letter along with the appeals form and as always, keep a copy for your files.
Common Reasons for Denial
The treatment or prescription is unlikely to cause your health condition to improve is the biggest denial circumstance and is a little vague. Medicare is required to look at your total condition, not just a specific diagnosis or your chance at a full recovery.
There was a citizen who was denied for Lou Gehrig's disease which is incurable and degenerative. The patient successfully appealed, arguing that with the doctor's help, that while having a nurse visit the home would not improve the condition, it could slow the progression of the disease and was need to care for various health issues.
Sometimes patients are denied because they may require long term care. You need to point out that Medicare is not limited to treatments that work quickly. As long as your doctor continues to order this treatment for you, Medicare should continue to cover it. Include a letter from your doctor if denied for this circumstance explaining that the treatment is having some positive effect or expressing an optimistic expectation that it will.
There are several other types of denial and you want to be specific to address the denial and use your primary care physician with a letter expressing an opinion that is different that Medicare's conclusion.
Don't give up
Sometimes you may have to go to Appeal #2 where you'll have 180 days from the date your redetermination request is denied. You must completed Medicare Reconsideration Request Form (Form CMS-20033, at www.CMS.HSS.gov). You may have to ask your doctor to write a new letter or attach the old letter. Sometimes it is about hanging in there and being determined.
You may have to take it to Appeal #3 if your second appeal is denied and the amount in dispute is over $120. You have 60 days to file a third appeal, this time with an Administrative Law Judge (ALJ) of the US Dept of Health and Human Services. The filing instructions would be included with the denial letter.
Appeal #4 If the judge turns you down you have 60 days to request that Medicare Appeals Council (MAC) review the decision. The ALJ denial will include instructions on how to file.
Appeal #5 If the MAC turns you down you have 60 days to determine if you wish to hire an attorney and file a judicial review in federal district court. The amount in dispute must be greater than $1,180 to qualify.
I hope this helps a few Seniors and empowers them to fight their fight for benefits.