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Posted 08/26/2021

A Guide to Medicare Advantage Appeals

A Guide to Medicare Advantage Appeals

So you've had a claim denied by your Medicare Advantage Plan. Before you throw in the towel and pay for the denied service yourself, you should consider filing an appeal.

Medicare Advantage appeals are a process that Medicare beneficiaries can use to appeal Medicare decisions about their Medicare coverage. This guide will provide you with an overview of the Medicare Advantage Appeals Process, including what triggers a Medicare denial, how to file a Medicare appeal, and what happens after filing an appeal.

Reasons for Service or Procedure Denials

The most common reason for payment denial is that the service was not deemed medically necessary. This means that there is a discrepancy in what the provider sees as important to treatment versus what the insurance company says is necessary.

If payment for a service is denied, it is NOT necessarily true that it was not medically necessary!

While this is the most common reason for denial, there are other reasons.

  • Failure to get prior approval for treatment when required
  • Using an out-of-network provider instead of an available in-network provider
  • Treatment received while participating in a clinical trial

Reasons for Prescription Drug Denials

There are many reasons a prescription drug can get denied by your health plan.

  • The drug is not on your plan's formulary.
  • Prior authorization was not obtained (not required for all drugs).
  • The prescribed dosage or form is not covered under the plan.
  • The pharmacy used is not within the plan's limits.
  • The drug has been deemed not medically necessary.

The Medicare Appeals Process

Service or Procedure Claim Appeals

If you are informed that the initial determination for a procedure or service has been denied, the appeal process will be outlined on the denial. (You can also read the information in your plan materials.) Oftentimes, the provider who performed the denied service will help with the appeal process.

An appeal must be initiated within 60 days of the denial. If an appeal is filed later than that, you must also include the reason for the late appeal.

Your Medicare claim appeal should be very detailed. Include all of the pertinent personal information, including your Medicare ID. Also include all details about the denied procedure: when it took place, the service for which you are requesting payment reconsideration, and a detailed explanation of why you believe the service should have been approved. Any other information you can include is helpful.

Timeline for the Service Appeal

The appeal process for a Medicare claim decision is not quick. There are cases when you can file for an expedited appeal, especially if your health is at risk during the appeal process. Otherwise, a standard appeal request will take approximately 30 days. A payment request may take twice that long.

If additional information is requested, it can prolong that process even further, which is why it is important to include all information on the initial appeal.

Prescription Drug Claim Appeals

The first step in filing a prescription drug appeal is to find out why coverage was denied. Your pharmacy will likely be able to give you this information. However, to obtain an official denial, you will need to contact your Medicare Part D plan and ask for the "Coverage Determination."

An appeal for prescription drug coverage in a Medicare drug plan could take place at two points.

  1. Appeal asking to be reimbursed for drugs you have already purchased

This appeal must be submitted in writing by either yourself or the provider who prescribed the medication. A "Model Coverage Determination Request" form must be completed. This form, along with more detailed instructions, can be found at CMS.gov.

Submit the completed form to your prescription drug plan.

2. Appeal asking for coverage on prescription drugs you have not yet purchased

There are typically 3 ways to ask for coverage on prescription drugs that have yet to be purchased. However, consult your plan documents as each insurance company has its own set of requirements.

Complete the "Model Coverage Determination Request" form and submit it to your plan's carrier.

Write a letter to your plan, including the prescription drug name and reason for prescribing it.

Call a representative of your plan and ask for coverage. (Be sure to take good notes, including the person you spoke to and a reference number for the call.)

Asking for an exception to the coverage

When asking for an exception to standard coverage, the provider prescribing the drugs will need to write a letter that explains the medical necessity for the exception.

Timeline for the Prescription Drug Coverage Appeal

Thankfully, these appeals are much quicker than service appeals!

Expedited requests take approximately 24 hours. You or your health care provider may ask for an expedited request if your health is at serious risk and there is not enough time for a standard request.

Standard requests take approximately 72 hours.

Payment requests can take approximately 14 days.

One last note about the appeal process. Make sure to take notes and make copies of anything you submit to your plan. If the paperwork gets misplaced by the company, it is wise to have a copy so that you do not have to track down all pertinent information again.

Lastly, understanding your Medicare Advantage Plan and its rules can help you avoid denials in the first place. Make sure you are visiting a provider in your network when available, review the necessity of procedures with your provider, and submit prior authorizations when needed.

The fastest way to get an appeal approved is to not have to file one!  Sometimes working with a Medicare Agent can help.  

For even more information on how to file an appeal and for other helpful links, visit Medicare's official website, Medicare.gov.

This was originally posted on CertifiedMedicareAgents.com.