Was Your Medicare Claim Rejected? Here’s How to Appeal

This content originally appeared on diaTribe. Republished with permission.

By Kara Miecznikowski and Eliza Skoler

Learn how to appeal a Medicare claim rejection under traditional fee-for-service Medicare, a Medicare health plan, or Medicare prescription drug coverage

A health insurance claim is a bill for your healthcare services, medications, or medical equipment that you think should be covered by your insurance plan. If you have Medicare health insurance, your healthcare practitioner will usually submit claims directly to Medicare for payment. If Medicare decides to reject the claim, you can challenge the decision. This is called an appeal.

In the United States, people have the right to appeal a denied claim for up to six months after hearing about this decision. Appeals can often be successful – a 2018 report showed that 75% of Medicare Advantage denials were overturned in the appeals process – which means that challenging a denied claim could save you money. This article will explain how to appeal a Medicare claim rejection.

To learn more about the appeals process in the United States – especially if you have a different health insurance plan – read our article, “When Insurance Gets Turned Down: Appeals Explained.”

How do Medicare appeals work?

You can appeal a decision made by the national Medicare fee-for-service program (Parts A and B), your private Medicare health plan (Part C), or your Medicare Prescription Drug Plan (Part D). Learn more about the different types of Medicare here.

Click to jump down to:

Appeals under Medicare Part A or B (“Original Medicare”)

Appeals under Medicare Part C (Medicare Advantage health plan)

Appeals under Medicare Part D (prescription drug plan)

Here are some common situations for appealing a claim rejection:

  • If you have already received the service, medication, or medical supplies. Example: your doctor gives you lab tests during a visit, but then Medicare rejects the claim.
  • If your doctor requested the service, medication, or medical supplies for you. Example: your doctor says you need an insulin pump and Medicare decides that is not medically necessary.
  • If you and your doctor request a change in price for your medication, based on what treatments work for you. Example: generic drugs do not work for your condition, so your doctor asks for a discount on the more expensive drug.

The appeals process is different under Medicare Part A, B, C, or D. There are five levels to the appeals process. If you disagree with the appeal decision at level one, you can continue to appeal the decision again at every other level.

With each appeals processes, write your Medicare number on every document you submit for your appeal, and keep a copy of all the materials you send in.

Filing an appeal under Medicare Part A (hospital insurance) or Part B (medical insurance), often called “Original Medicare:”

  • Your bill will be sent directly to Medicare.
  • The appeal must be filed within 120 days of receiving the Medicare Summary Notice (MSN) that shows that your claim was denied.
  • If you disagree with a Medicare coverage decision in the MSN, you can appeal the decision.

A Medicare Summary Notice (MSN) is a summary of the health care services you have received over the past three months, sent to you by mail.  It shows what Medicare paid for each service and what you owe for the service, and it will show if Medicare fully or partially denied a medical claim. The MSN also contains your appeal rights and step-by-step directions on when and how to file an appeal for a claim rejection.

Did you sign an Advanced Beneficiary Notice of Noncoverage (ABN) before you received the treatment? An ABN is a notice that your healthcare provider will give you if they think the health services they are recommending might not be covered by Original Medicare. Your ABN will list the items that Medicare is not expected to pay for, as well as the estimated costs of those health services. The ABN can help you decide if you would still like to receive the treatment, and if you will pay for it if Medicare declines to cover the cost.

When you sign an ABN you can ask your healthcare provider to submit the claim to Medicare (before billing you), asking Medicare to cover the cost. If Medicare rejects the claim, you can appeal the decision. If your healthcare provider did not give you an ABN before treatment, you might not be responsible for paying for the health service. Learn more ABNs and appeals here.

There are three different ways to file an initial appeal under Original (Part A or B) Medicare:

appeals

Image source: iStock Photo

  • Fill out a “Redetermination Request Form” with information from your MSN; send the form to the address provided on your MSN
  • Follow instructions on your MSN for filing an appeal without using the form:
  1. Circle the claim that you disagree with on your MSN
  2. On a separate piece of paper, explain why you disagree with the decision
  3. Write your name, address, phone number, and Medicare number on the MSN, and sign it
  4. If you have any other information that will support your case, include it; you can ask your doctor or other health care provider to help you
  5. Send all of the above materials to the address listed under “Appeals Information” on your MSN
  • Or, send a written request to the company that processes Medicare claims. Include:
  1. Your name and Medicare number
  2. The item that you disagree with on the MSN
  3. An explanation of why you disagree with the decision
  4. Your signature
  5. Send all of the above to the address provided under “Appeals Information” on the MSN

You should receive a decision within 60 days of your request, unless you submit extra information after you first file the appeal (which may delay the decision).

For more information on the Original Medicare initial appeals process, see the Medicare webpage. If you disagree with the appeal decision at the first level, you have 180 days to file an appeal at the second level; information on the appeals process beyond level one can be found here.

Filing an appeal under Part C (Medicare Advantage health plans):

  • The initial appeal must be filed within 60 days of receiving the claim rejection.
  • You must send a written request (unless your plan allows you to file a standard request by phone, fax, or email instead).

In your request, include:

  1. Your name, address, and Medicare number
  2. The item you disagree with, the date that you received the service, and an explanation of why you disagree with the decision
  3. Any other information that may support your case

You should receive a decision about your appeal within 60 days, unless Medicare needs more time to obtain information from your healthcare provider. If waiting for a decision will hurt your health, your appeal decision will be made within seven days.

If your appeal is rejected (fully or partially), your request will automatically be sent to level two of the appeals process. More information on the initial appeals process under Medicare Part C can be found here. For information on the process after level one, click here.

Filing an exception request or appeal under Medicare Part D (prescription drug plans):

  • Reasons to request an exception to your Part D drug plan:
    • If your plan decides not to provide a medication you think should be covered.
    • If cheaper versions of your medication don’t work for you, you can ask for a discount on the more expensive medication.
    • If a drug you need is not on your plan’s drug list, you can ask for an exception.
  • An exception request must be submitted first; if your exception request is denied, you have 60 days to appeal the prescription drug claim rejection.
  • You must send a written request (unless your plan allows you to file it in another way).

An “Evidence of Coverage” document explains your rights with your Medicare prescription drug plan. You have the right to ask your plan to pay for a medication you think should be covered, and you have the right to request an appeal if you disagree with your plan’s decision to provide it.

appeals

Image source: iStock Photo

Before appealing a claim rejection, you will request an exception:

  1. Fill out a Medicare Prescription Drug Coverage Determination request form through your insurance plan sponsor
  2. Ask the healthcare provider who prescribed your medication to write a letter explaining why you need this medication
  3. Send the documents to your Medicare health plan

You should hear back about your request within 72 hours. If your exception is denied, you can appeal the claim rejection. To submit a written appeals request, include:

  1. Your name, address, and Medicare number
  2. The drug you want your plan to cover
  3. An explanation of why you are appealing the coverage decision.
  4. Any other information that may support your case, including medical records
  5. Send the documents to your Medicare health plan

You should receive a decision within seven days. If waiting for a decision will hurt your health, your appeal decision will be made within 72 hours.

More information on the initial prescription drug appeals process can be found here. If your request is not met (fully or partially), you have 60 days to appeal the decision at the next level; learn about further appeals here.

How can I get help filing an appeal?

You can have someone else file an appeal for you. This can be a family member, friend, lawyer, doctor, or anyone else that has agreed to be your representative. For more information and the representative form, see the Medicare website page on how to appoint a representative. For prescription drug appeals, your doctor or prescriber can request an initial appeal for you; you do not need to first fill out a form.

For more help with appeals, especially appeals beyond level one, contact your State Health Insurance Assistance Program (SHIP). SHIP is a network of free counseling services that help people navigate Medicare; find the SHIP program in your state here.

diaTribe Series

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This article is part of a series on access that was made possible by support from AstraZeneca. The diaTribe Foundation retains strict editorial independence for all content. 

Source: diabetesdaily.com

Prior Authorization: Getting Diabetes Supplies and Medications Covered by Insurance

This content originally appeared on diaTribe. Republished with permission.

By Divya Gopisetty

What is a prior authorization? Read on to learn more about why diabetes supplies or medications might require a prior authorization and how to go through the process

It can be frustrating to learn that you need a prior authorization when you already have a prescription. Insurance plans sometimes require a prior authorization to cover a diabetes supply, device, or medication, even if your doctor prescribed it to you.

Read on to learn about what a prior authorization is, and how you can make the submission process as smooth as possible.

In this article:

Click to jump to a specific section!

What is a prior authorization?

My pharmacist told me I need a prior authorization. What happens next?

How can I check if I need a prior authorization?

How long do prior authorizations last?

What happens if the prior authorization is denied?

What is a prior authorization?

A prior authorization, also known as a pre-authorization or pre-certification, means that your healthcare provider or device company has to get specific approval from your health insurance company (so that it will pay for it).  The requirements for prior authorization differ between and within insurance plans.

If you need a prior authorization, the pharmacist cannot process your prescription until your healthcare professional has contacted the insurance company. Similarly, a device company may not ship your diabetes device to you until it has prior authorization from the insurance company.

A prior authorization is designed to make sure certain prescription drugs or devices are used correctly and only when medically necessary. Before your insurance plan will cover a certain device or drug, you must show that you meet a set of criteria.

Prior authorizations are most often handled by your healthcare professional’s office, but sometimes are handled by the device company itself (e.g., for CGM).

If you want to see what a prior authorization request form looks like, check out this one for OptumRx.

My pharmacist told me I need a prior authorization. What happens next? 

  1. If your insurance company requires (and has not received prior authorization), your pharmacy will contact your healthcare professional.
  2. The healthcare professional will contact your insurance company and submit a formal authorization request.
  3. Your insurance plan may have you fill out and sign some forms.
  4. Your insurance plan will contact the pharmacy once it has approved or denied the request.

During this process, be sure to communicate with both your healthcare provider and your insurance company to see if they need any additional information. Prior authorizations usually take about a week to process – after that, check with your pharmacy to see if the request was approved. If the request was approved, you should be able to pick up your prescription from the pharmacy.

If it wasn’t approved, your pharmacy should be able to tell you why, and then you can decide to request an appeal.

As someone living with diabetes, you are your best advocate. Be prepared to track down the paperwork to make sure you receive the requested device or medication.

How can I check if I need a prior authorization?

Check your health plan’s policy and formulary (you can normally access these on the insurance company’s website) to see if any of your treatments require a prior authorization. Or, you can call the member services number found on the back of your insurance ID card to speak with someone directly.

How long do prior authorizations last?

Most approved prior authorizations last for a set period of time (usually one year). Once it expires, you’ll have to go through the prior authorization process again.

What happens if the prior authorization is denied?

  • You can request an appeal (which is often successful!)
  • You can pay the full cost for the medication or healthcare supply, without insurance coverage.

Want to learn more?

Check out this easy-to-read resource created by DiabetesSisters on prior authorizations, step therapy, and appeals.

What’s Worked for Other People with Diabetes? Hear from Them!

  • I was denied my first CGM in 2008 by a Blue plan and fought and won by knowing how to Google my payer’s medical policy and prove that I met coverage criteria. It helped that I was given the HCP line phone number by a nurse sympathetic to my cause, but I ended the call with an authorization code. – Melissa
  • My strategy has always been persistence pays (eventually the insurance company will give in, although they may have peculiarities to navigate. The doctor’s office is really key and many have specialists who only deal with insurance company issues [mine does]). I’ve been covered by 4 insurance companies over the past decade while at the same employer if that tells you anything about the evolving insurance market. My experience with Anthem was a hassle but predictable, United Healthcare was easiest to navigate, Aetna was straightforward but a pain and had some weird rules (Why does a precertification inexplicably expire at the end of a calendar year? My chronic illness did not expire at the end of the year.). – Scott
  • Do you have experiences with prior authorizations? Let us know!
diaTribe Series

Image source: diaTribe

This article is part of a series on access that was made possible by support from AstraZeneca. The diaTribe Foundation retains strict editorial independence for all content. 

Source: diabetesdaily.com

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