How to Appeal a Medicare Ruling
- 1). Determine the type of coverage that was denied. Medicare has Parts A, B, C and D, and each covers a different type of care. Part A is in-hospital care; Part B is outpatient care; Part C is private managed care; Part D is drug coverage. The type of appeal you file depends on which claim or application was denied.
- 2). Send a Medicare Redetermination Request Form to Medicare asking for an appeal within 120 days of the decision if your denial was for Part A or Part B coverage. This is how to request a redetermination. In the letter, tell Medicare why its decision is wrong. Your doctor may be willing to provide you with additional proof. Include the Medicare Summary Notice that you received notifying you of the denial with your letter. Part C and D coverage appeals follow the same procedure, except it's expedited and is often administered by the prescriber of the medications/treatment. Contact information for appeals is included in the Medicare Summary Notice.
- 3). Complete an Appointment of Representative form if you need help fighting the ruling. Medicare allows recipients to appoint a personal representative to assist with the appeal. This representative can be anyone you choose, and the form must be submitted with the appeal letter.
- 4). Wait for a decision. Medicare takes about 60 days to respond to Part A and B appeals; Part C and D appeals decisions can be made immediately if the situation is life-threatening.
- 5). Appeal the ruling again by filing a Medicare Reconsideration Request Form if the redetermination is denied. This step is called reconsideration, and it must be sent to the qualified independent contractor named in the redetermination denial within 180 days.
Wait again for 60 days for a decision. - 6). Continue to escalate your claim if your reconsideration appeal is denied: File a Request for Medicare Hearing by an Administrative Law Judge. The third, fourth and fifth appeals go to an administrative law judge hearing, the Medicare Appeals Council and the federal district court, respectively. Each denial will include instructions on how to proceed to the next appeal level.
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