If your Medicare Advantage Plan denies a request for coverage or reimbursement for health care services under Medicare Part C, you have the right to appeal if you disagree with the decision.
Medicare Part C Standard Appeal Basics
Medicare Advantage Plans (MA Plans) allow Medicare recipients to obtain their health care through private managed care insurance plans under Medicare Part C. As a Medicare Advantage Plan member, you are entitled to the same protections and rights as beneficiaries under Original Medicare, including the right to appeal if the Medicare Advantage Plan denies your request to provide coverage or reimbursement for a service that you believe is medically reasonable and necessary.
Your Medicare Advantage Plan must provide you with information regarding the appeal process as part of your Plan materials. You can also contact your Medicare Advantage Plan for information regarding your appeal rights. You must be sure to follow the correct appeals procedure, as there is a difference between appealing decisions under Medicare Part C from the appeal procedures for Medicare Parts A and B.
There are up to five potential levels of standard appeals that a Medicare Advantage Plan member can pursue for a Medicare Part C denial. The first three levels of the standard appeals process are quite easy to navigate as long as you follow the instructions at each level of appeal, particularly with respect to the time deadlines for filing your appeal.
The later stages of appeal have a minimum claim amount in dispute requirement, also called the amount in controversy (AIC).
The Organization Determination Notice
After you have requested that your Medicare Advantage Plan give you prior authorization for or reimburse you for a medical service or item which you think should be covered, you will receive a written Organization Determination. This document will state whether your Medicare Advantage Plan will pay or deny coverage or reimbursement. The Organization Determination will also provide a reason for the denial and give you instructions on how to request an appeal.
Level 1 Appeal - Request for Reconsideration by the Plan
The first level of a Part C appeal is called a Request for Reconsideration. You may request that your Medicare Advantage Plan reconsider the decision within 60 days of receiving the Organization Determination. Your Medicare Advantage Plan will conduct an on-the-record of your claim file, meaning the reconsideration is based on your medical records alone, and you will not need to appear in person. Generally, you will receive a reconsideration decision within 30 days if the decision involves a request for service (for example, a prior authorization to see an out-of-network physician) and 60 days if the decision involves a request for payment (for example, reimbursement for a service you have already paid for out of your pocket).
Level 2 Appeal - Reconsidered Determination by an Independent Review Entity
Your Level 1 appeal will be automatically forwarded to the Level 2 appeal process in two situations: first, if your Medicare Advantage Plan fails to give you a decision within the response deadlines noted above; or second, if the Medicare Advantage Plan does not decide in your favor during the Level 1 review. In either case, the Medicare Advantage Plan is required to automatically forward your appeal to an outside Independent Review Entity (IRE) for a Level 2 review.
The Independent Review Entity is hired by Medicare and will conduct a new and independent on-the-record review of your claim. There is no minimum amount in controversy (AIC) required for a Level 2 appeal. The Independent Review Entity will send you its decision in writing and it will contain information regarding your right to appeal to the next level, before an administrative law judge.
Level 3 Appeal: Administrative Law Judge Hearing (ALJ)
If the Level 2 decision was not in your favor and you still disagree with the denial, you may file a Level 3 Request for Hearing with the Office of Medicare Hearings & Appeals (OMHA) before an administrative law judge, also called an “ALJ”. The minimum amount in controversy for a Level 3 appeal is at least $130 (in 2012). The amount in controversy requirement changes annually, but it will always be indicated in your Level 2 decision.
You must file your Request for Hearing within 60 days of receiving the Level 2 Decision. OMHA and its ALJs are independent of Medicare and are part of the U.S. Department of Health & Human Services. Most hearings are held by telephone or videoconference (VTC) from one of numerous remote sites. You may also have an in-person hearing at one of the four field offices if you can show the ALJ that “good cause” exists for you to appear in person. In some cases, the ALJ may decide to forgo a hearing altogether and may decide the case “on-the-record” when the evidence in the claim file supports a decision in your favor.
You should consider whether to obtain legal advice before requesting an ALJ hearing. The hearings are informal proceedings and you are not required to know the rules of evidence to present your case, so attorneys aren't required, but having an attorney represent you can increase your chances of winning the appeal. You may also appoint a personal representative, such as a spouse, friend, caregiver, or patient advocate to appear on your behalf.
You can also present witnesses to testify on your behalf. The ALJ may ask other witnesses, including physicians or other experts, to attend the your hearing. You will be able to ask questions of any witness who testifies at your hearing. All hearings are conducted are audio recorded.
Level 4 Appeal: Medicare Appeals Council Review
If you receive an unfavorable Level 3 ALJ decision, or the ALJ dismissed your case, you have 60 days from the date shown on the ALJ decision to file a written Request for Review with the Medicare Appeals Council (MAC). At this level of appeal, the remaining amount in controversy (AIC) must be at least $130 (in 2012). The MAC review is conducted on-the-record and is independent of OMHA and the Level 3 ALJs. You should consider talking to a lawyer before requesting a MAC Review.
Level 5 Appeal: Federal District Court Civil Lawsuit
If you disagree with the MAC’s Level 4 Decision and the amount in controversy (AIC) is at least $1,350 (in 2012), you can file a civil action in your local federal district court. Your lawsuit must be filed within 60 days of receiving the unfavorable MAC Decision. This is the last level of appeal available to you. The MAC’s Notice of Decision will give you information about filing a lawsuit, but as this is a formal court proceeding, you should probably hire a Medicare lawyer to help you file the lawsuit.
Where to Get Additional Information
You may also want to check out Nolo's book Social Security, Medicare & Government Pensions, by Attorney Joseph Matthews.