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Navigating the Insurance
Appeal Maze - How to Win
and Get Coverage
March 26, 2014
Niketa Sheth
Senior Vice President, Quality of Life
Christopher & Dana Reeve Foundation
Bernadette Mauro
Director, Information and Resource Services
Christopher & Dana Reeve Foundation
Bill Cawley
Manager, Peer & Family Support Program
Christopher & Dana Reeve Foundation
Carlos Caprioli
Information Specialist and Translator
Christopher & Dana Reeve Foundation
Appealing Medicare
Coverage Decisions
Medicare Summary Notice (MSN)
• Review your “Medicare
Summary Notice (MSN).” If you
disagree with a coverage or
payment decision, you can
appeal.
• You’ll get an MSN in the mail
every 3 months. You must file
an appeal within 120 days of the
date you receive the MSN.
Source: Medicare.gov
5 Levels of Appeal (Original Medicare)
1.
Redetermination by the company that handles claims for
Medicare
2.
Reconsideration by a Qualified Independent Contractor (QIC)
3.
Hearing before an Administrative Law Judge (ALJ)
4.
Review by the Medicare Appeals Council (Appeals Council)
5.
Judicial Review by a Federal District Court
Source: Medicare.gov
Level 1: Redetermination
Options for Requesting a
Redetermination:
1. Fill out a standard CMS
"Redetermination Request Form"
and send it to the Medicare
contractor at the address listed on
the MSN.
2. Send a copy of the MSN to the
company that handles bills for
Medicare (listed on the MSN) asking
for a review.
3. Send a letter to the company that
handles bills for Medicare.
Source: Medicare.gov
Level 2: Reconsideration
Options for Submitting a
Reconsideration Request:
1. Fill out a "Medicare
Reconsideration Request Form.”
2. Submit a written request to the
QIC.
Source: Medicare.gov
Level 3: Hearing Before an
Administrative Law Judge (ALJ)
Options for Requesting a Hearing:
1. Fill out a "Request for Medicare
Hearing by an Administrative Law
Judge" form.
2. Submit a written request to the
OMHA office that will handle your
ALJ hearing.
Source: Medicare.gov
Level 4: Review by the Medicare
Appeals Council
Options for Requesting an Appeals
Council Review:
1. Fill out a "Request for Review of
an Administrative Law Judge (ALJ)
Medicare Decision/Dismissal"
form.
2. Submit a written request to the
Appeals Council.
Source: Medicare.gov
Level 5: Judicial Review by a Federal
District Court
•
To get a judicial review in federal district court, the amount of your case must meet a
minimum dollar amount. For 2014, the minimum dollar amount is $1,430. You may be
able to combine claims to meet this dollar amount. Follow the directions in the decision
letter you got in level 4 to file a complaint.
•
If you want your doctor or other prescriber (for prescription drug appeals) to request
this level of appeal on your behalf, you’ll need to submit an “Appointment of
Representative” form.
Source: Medicare.gov
Original Medicare vs. Medicare Advantage
Coverage and Payment Notices
•
•
Original Medicare: Medicare Summary Notices (“Initial Determinations”)
Medicare Advantage and Part D Drug Plans: Explanation of Benefit Statements
(“Organizational Determinations”)
Appeals Deadlines for the First Level of the Appeal Process
•
•
Original Medicare: 120 Days
Medicare Advantage and Part D Drug Plans: 60 Days
Qualified Independent Contractor (QIC) vs. Independent Review Entity (IRE)
•
In the second level of the appeal process, a Qualified Independent Contractor (QIC) is the
organization that decides on appeal under Original Medicare. For Medicare Advantage and
Part D, an Independent Review Entity (IRE) makes the decision.
Source: Health Assistance Partnership – Medicare Appeals Rights and Procedures
Appealing Medicaid
Coverage Decisions
Know Your Rights!
• Prior written notice of adverse action
• Fair hearing before an impartial decision-maker
• Continued benefits pending a final decision
• Timely decision measured from the date the complaint is
first made
Source: Kaiser Family Foundation: A Guide to the Medicaid Appeals Process
Written Notices
At least 10 days (typically) before taking an action
that affects a beneficiary’s coverage, state Medicaid
agencies must send a notice that includes (among
others) the following information:
•
The action (e.g., denying a claim)
•
An explanation for the action
•
Explanation of your right to request a hearing
and the process for requesting a hearing in your
state
•
Your rights for hearing representation (e.g.,
yourself, legal counsel, other spokesperson)
•
An explanation of the circumstances under
which your benefits will continue if a hearing is
requested
Source: Kaiser Family Foundation: A Guide to the
Medicaid Appeals Process
Requesting a Hearing
Requirements for requesting a hearing vary by state,
but will be outlined in the written notice of action
you receive in the mail.
•
Remember:
– Be aware of your state’s established
timeframe for requesting a hearing
(generally between 20 and 90 days from
the date a notice of action is mailed)
– Your request can only be denied if you
withdraw the request in writing or fail to
appear
– If you are currently receiving services, you
have the right to request that those
services continue until a final hearing
decision is issued
NOTE: If you receive services through a Managed
Care Organization (MCO), you have a right to a
hearing; however, you may be required to exhaust
the MCO’s appeal process first.
Source: Kaiser Family Foundation: A Guide to the
Medicaid Appeals Process
Preparing for Your Hearing
Gather Documents: Prepare a list of / copy all of the documents,
photos, or other materials you want the hearing officer to use in
making the decision. This includes letters from doctors, medical
records, letters or emails to and from Medicaid or your
caseworkers.
Prepare a Written Statement: Write down the important facts of
your case and why you think Medicaid’s action is wrong (e.g., the
services are medically necessary). You will be able to make
opening remarks before the testimony and closing remarks after.
You can give the hearing officer a “brief” before the hearing, if
you are able. A brief is a written document with the facts, your
arguments, and supporting evidence.
•
Bring Your Medicaid Notice: Ask the hearing officer to review the notice. If you think the notice left out any
important information, say so.
•
Identify Witnesses: Find witnesses who can help support your side of the case (e.g., your doctor or nurse,
caregivers, family members, etc.). If your witnesses cannot attend the hearing, ask them to write a letter
explaining why your services are medically necessary. Get the letter notarized, if possible.
•
Prepare Questions: Prepare a list of questions you want to ask your witnesses, as well as witnesses attending
your hearing on behalf of Medicaid.
Source: Protection and Advocacy for People with Disabilities, Inc.
Hearing Decisions
You will receive a decision in writing within 90 days of the date
you asked for a hearing.
• If you win…
– Medicaid will make corrective payments, retroactively
• If Medicaid wins…
– Medicaid will notify you of your right to have the hearing decision
reviewed by a state court
– If you received services throughout the hearing, you may have to
reimburse Medicaid for those services
Source: Kaiser Family Foundation: A Guide to the Medicaid Appeals Process
Appealing a Private
Insurer’s Decision Not
to Pay
Internal Appeal
• An appeal directly to your insurance company
• Must be filed within 180 days of claim denial
• Complete all insurance company forms or write to your insurance
company with your name, claim number, and health insurance ID
number
• Submit any other information you want the insurance company to
consider when evaluating your appeal
• At the end of the internal appeals process, your insurance company must
provide you with a written decision
Source: marketplace.cms.gov
External Appeal
•
Must be filed in writing and within the timeframe established by your health
insurance company (typically within 60 days of the date your insurer sent you a
final decision)
•
You may appoint a representative to file the review on your behalf
•
The written final denial of your internal appeal will include the contact
information for the independent third party that will handle your external
review
•
The external reviewer will issue a final decision – your insurance company must
accept the reviewer’s decision
•
External reviews are decided as soon as possible (no later than 60 days after the
request was received)
•
You may qualify for an expedited external review
Source: marketplace.cms.gov
Tips for a Successful
Appeal
Tips for a Successful Appeal
• Know the appeals process (e.g.,
deadlines, options, etc.)
• Keep accurate and comprehensive
records (e.g., medical records,
denial letters, letters from your
provider(s), your own personal
notes, etc.)
• Ask your doctor for a letter of
medical necessity
• Be persistent!
We Can Help!
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