If you have a Medicare Advantage Plan, you know it covers a lot of items and services, like prescription drugs, diabetic test supplies, cardiovascular screenings, and hospital visits. What should you do if your plan won’t cover the cost of an item or service you need? If you disagree with the plan’s initial decision, you can file an appeal.
You have the right to ask your Medicare Advantage Plan to provide or pay for items or services you think should be covered, provided, or continued. To resolve these differences with your plan, learn how to file an appeal.
Here are 4 tips to help you get started:
- Get Help: If you want help filing an appeal, contact your State Health Insurance Assistance Program (SHIP) or appoint a representative. Your representative could be a family member, friend, advocate, attorney, doctor, or someone else who will act on your behalf.
- Gather information: Ask your doctor, other health care providers, or supplier for any information that may help your case.
- Keep copies: Be sure to keep a copy of everything you send to your plan as part of your appeal.
- Start the process: Follow the directions in your plan’s initial denial notice and plan materials. You have 60 days from the date of the coverage determination. If you miss the deadline, you must provide a reason for filing late.
There are 5 levels to the appeal process. If you disagree with the decision at any level of the process, generally you can go to the next level. At each level, you will get instructions in the decision letter on how to move onto the next level of appeal.
Level 1: Reconsideration from your plan
Level 2: Review by an Independent Review Entity (IRE)
Level 3: Decision made by the Office of Medicare Hearings and Appeals (OMHA)
Level 4: Review by the Medicare Appeals Council (Appeals Council)
Level 5: Judicial review by a federal district court
As a client of Group Plans Inc, we can offer you assistance, if you are still unsure how to navigate the appeal process. If you would like more information on obtaining a Medicare Advantage Plan, please contact us at (623) 889-7600