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Appeals Process for Claims

This FAQ answers some common questions about how to appeal a denied claim.

Appeals Process for Claims

I have Medicare and also other healthcare coverage. Who pays first?

Generally, if you have Group Health Insurance coverage from an employer or from a spouse’s employer (employer should have 20 or more employees) and also Medicare, the Group Plan is primary and pays first.

Otherwise, usually Medicare is primary and pays first, though there are  exceptions. Refer to this topic in detail on the ‘About Medicare’ tab.

Medicare denied a claim which I think should have been paid. What should I do?

You can challenge the decision by filing an appeal within 120 days of receiving the Medicare Summary Notice that lists the denied claim.

Who can I contact to resolve Medicare claim payment issues?

You should contact your plan to get information about how to file an appeal. In most cases, this information should already be part of the plan materials or on the back of your plan’s membership card.

Is there a way I can appeal Medicare's decision to deny my claim?

Yes, you can appeal by contacting the Medicare Administrative Contractor listed on the Medicare Summary Notice.

How do I file an appeal with Medicare?

You can contact your State Health Insurance Assistance Program (SHIP).

If you need help filing an appeal, you can appoint a representative, who could be anyone including your family members.

What if my appeal is not successful?

There are five levels of appeals. Below is an example of a fast-track appeals process.

Inpatient Hospital Appeal example:

If the hospital says you must leave and you think it’s too soon, appeal to the Quality Improvement Organization (QIO) by midnight of the day of your discharge. The QIO should make its decision and call you within 24 hours of receiving all the information it needs.

If your appeal to the QIO is not successful, you will not be held responsible for the cost of the 24-hour period during which you waited for the QIO to make a decision. But if you remain in the hospital after that period, you may be responsible for the cost of your care if you do not win at a higher level of appeal.

If needed, you can move to the next level by appealing to the Qualified Independent Contractor (QIC) by noon of the day following the QIO's denial. The QIC should make a decision within 72 hours. If you continue to stay in the hospital, you cannot be charged until the QIC makes a decision. However, if you lose your appeal, you will be responsible for the cost of the stay.

If the appeal to QIC is denied, you can choose to move to the next level by appealing to the Administrative Law Judge (ALJ) within 60 days. Amount in question should be $160 or more. If you decide to appeal to the ALJ, it may be a good idea to contact a lawyer or legal services organization to help you with the process. The ALJ should make a decision within 90 days.

If your appeal to the ALJ is denied, you can choose to continue to the next level by appealing for a Medicare Appeals Council (MAC) review within 60 days of the date on your ALJ denial letter. There is no deadline for the MAC to make its decision.

If your appeal is still denied you can choose to appeal to the Federal District Court within 60 days of the date on your MAC denial letter. The amount in question should be $1,630 or more. There is no timeframe for the District Court to make a decision about your appeal.

                                                                                                                                                  

Click here to learn more about Medicare, its various Parts, different enrollment periods and your costs. 

We have also created videos to help you better understand various topics related to Medicare. Select and watch a video explaining the topic of your interest in a simple and intuitive manner.

Remember that you cannot choose just any combination of Parts and Plans. Let Lighted Road Insurance guide you step-by-step through the Medicare ecosystem and help you in selecting the right plan(s) for your needs. 

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Last Updated: 08-09-2019