Friday, July 15, 2016

Medicare Appeals - The Real Story

Medicare Appeals - The Real Story

If you are on Medicare and you have a service which is not paid the way you think it should be, or your have trouble with a Part D plan, your option is to do an appeal.  There are some tricks to this which most people do not know. 

First, there is a separate and distinct process, depending on what you are appealing.  Part D is a different  process than for medical claims.  So, let's talk about Medical claims first.

When a Medicare recipient goes to any provider for services, Medicare keeps track of those services.  On a periodic (not monthly) basis, Medicare will send out a Medicare Summary Notice.  This notice has information about all of the services you have had during the reporting period.  It can take several months for Medicare to send out this notice to you. The notice can contain multiple dates of service on it, too.

The most important thing you can do is to review the Medicare Summary Notice as soon as you receive it.   You may have bills for the previous quarter and not receive the notice until much later  This creates a problem, since according to Medicare, you only have 120 days from the date of service for you to appeal to Medicare. 

On the last page of the Medicare Summary Notice, there is information about appealing.  If you appeal, you must return a copy of the Medicare Summary Notice and all supporting documentation to the address on the Summary Notice. There is a date listed on the Notice that states how long you have to appeal.  Medicare must receive the normal appeal for that date and the appeal will be denied if you do not respond by then.  All appeals must be in writing and mailed.  Fax notifications are not honored.

Once the appeals vendor RECEIVES the notice, they have 60 days to even respond.  You cannot escalate your appeal before the 60 days is up. 

I have been successful in appealing Part D grievances with the Medicare Redetermination Request and Appointment of Representative form.  This has worked only for Part D.  What decisions have been made were concerning Late Enrollment Penalties (LEP) only. In addition, I was able to fax copies of the documentation in successfully.

The bottom line is this.  If you have a problem with Medicare, you are going to need an advocate to help you.  This is complicated, confusing and requires persistence to get problems resolved. 

If you would like more information, you can contact Lucy Grosz at 64-889-0934 or e-mail

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