How to Appeal Denied Medicare Claims
Every year Medicare will deny over 13 million claims for Hospitalization, of which, 300,000 appeals are filed. The success rate is 40% for the first of five rounds of appeal. Every year, 93 million doctor's visits and other services are denied and 2.5 million will appeal, of which, 53% will succeed in the first round. If your claim is denied, appeal it, not once, but up to five times.
Your appeal can be heard five times by different entities, not the same judge or others. Should you be denied four times, the final hearing will be in a federal district court. If you must go beyond the second appeal, make sure you have a medical advocate or an attorney. Make sure your denial was not due to a clerical service code error. Create a paper trail and send letters using certified mail and make copies of original documents. If you talk to anyone on the phone at medicare, take notes, note the date and name of person you spoke to. In each round of appeal, get your doctor's support by requesting records and a letter from them that states the reason for the claims denial and why you need the service or product.
When your claim was denied, this is indicated on the Medicare Summary Notice. Circle the claim you wish to be appealed and write "please review", then, sign and attach any supporting documents. You 120 days to do this. If the appeal is denied, request that an independent contractor reviews it and fill out a Medicare Reconsideration Request Form (go to cms.gov), this must be filed within 180 days of receiving a redetermination ruling. If the reconsideration is denied and if it is $130 or more, request a hearing before an administrative judge (Form 20034) and file within 60 days of being rejected for a reconsideration ruling. A judge will hear it by phone or video conference. To appeal the judge's ruling (if not in your favor) appeal this to the Medicare Appeals Council (Form DAB-101), file within 60 days. If the council does not rule in your favor and if the amount is $1350 or more, request a judicial review by a U.S. district court. Again, file within 60 days.
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