CHOICES Corner: Appeals
Have you ever disagreed with a decision Medicare made about coverage for a service or item? If you have, you have a right to appeal the decision. “An appeal is the action you can take if you disagree with a coverage or payment decision by Medicare or your Medicare plan. For example, you can file an appeal if Medicare or your plan denies: A request for a health care service, supply, item, or prescription drug you think you should be able to get or payment for a health care service; supply, item, or prescription drug you already got; or a request to change the amount you must pay for a health care service, supply, item, or prescription drug.”
In some instances, Medicare will not speak with your doctor or family about your problem, until you complete a request to appoint someone to serve as your representative in the appeal if you need help filing the appeal (See note 1.) In some cases, your doctor can make a request on your behalf without being appointed as your representative (See note 2).
There are 3 ways to request a redetermination:
1. Read your MSN carefully, and follow the appeal instructions: • Circle the item(s) and/or service(s) you disagree with on your MSN. • Explain in writing on your MSN why you disagree with the initial determination, or write it on a separate piece of paper along with your Medicare Number and attach it to your MSN. • Include your name, phone number, and Medicare Number on your MSN. • Include any other information you have about your appeal with your MSN. Ask your doctor, other health care provider, or supplier for any information that may help your case. Write your Medicare Number on all documents you submit with your appeal request. • You must send your request for a redetermination to the MAC at the address listed in the “File an Appeal in Writing” section of your MSN.
2. Fill out a “Medicare Redetermination Request” form (CMS Form number 20027). To get a copy, visit CMS.gov/cmsforms/ downloads/cms20027.pdf, or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. Send a copy of the completed form to the MAC listed on your MSN.
3. Submit a written request to the MAC. The company’s address is listed on your MSN. Your request must include: • Your name and Medicare Number. • The specific item(s) and/or service(s) you’re requesting a redetermination and specific date(s) of service. • An explanation of why you don’t agree with the initial determination. • The name of your representative, if you’ve appointed one. “
If you are unable to file your appeal and require assistance, call Center the for Medicare Advocacy and request help filing an appeal. Phone: (860) 456-7790.
* based on information provided at: Medicare.gov/publications/appeals
Note 1: To request a representative, submit a written request that includes: “• Your name, address, phone number, and Medicare Number (found on your red, white, and blue Medicare card) • A statement that you’re appointing someone as your representative to act on your behalf • The name, address, and phone number of your representative • The professional status of your representative (like a doctor) or their relationship to you • A statement authorizing the release of your personal and identifiable health information to your representative • A statement explaining why you’re being represented and to what extent • Your signature and the date you signed the request • Your representative’s signature and the date they signed the request If you’re appointing someone to help with your appeal, send the “Appointment of Representative form” or a written request with your appeal request to the Medicare Administrative Contractor (MAC) (the company that handles claims for Medicare), or your Medicare health plan. Keep a copy of all the paperwork.
Note 2: In some cases, your doctor can make a request on your behalf without being appointed as your representative.
If you have a Medicare Advantage Plan or other Medicare health plan: Your treating doctor can request an organization determination or certain pre-service reconsiderations on your behalf, and you don’t need to submit an “Appointment of Representative” form.” However, if you want your treating doctor to request a higher level of appeal on your behalf, you’ll need to submit a written request to appoint a representative.
If you have a Medicare drug plan: Your doctor or other prescriber can request a coverage determination, redetermination, or reconsideration from the Independent Review Entity (IRE) on your behalf, and you don’t need to submit an “Appointment of Representative” form.
*This article is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $577,477 with 100 percent funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. Government.