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How Do I File an Appeal Under Medicare?

Sudhir Mathuria  Licensed  Professional Health Life 360 6776 Southwest Freeway, Suite # 178 Houston TX 77074 713-771-2900 www.MyMedicarePlanning.com

Sudhir Mathuria
Licensed Professional
Health Life 360
6776 Southwest Freeway, Suite # 178
Houston TX 77074
713-771-2900

What’s an appeal?

An appeal is the action you can take if you disagree with a coverage or payment decision made by Medicare, your Medicare health plan, or your Medicare Prescription Drug Plan. You can appeal if Medicare or your plan denies one of these:
• Your request for a health care service, supply, item, or prescription drug that you think you should be able to get
• Your request for payment for a health care service, supply, item, or prescription drug you already got
• Your request to change the amount you must pay for a health care service, supply, item or prescription drug.
You can also appeal if Medicare or your plan stops providing or paying for all or part of a service, supply, item, or prescription drug you think you still need.
If you decide to appeal
If you decide to appeal, ask your doctor, health care provider, or supplier for any information that may help your case. See your plan materials, or contact your plan for details about your appeal rights. Generally, you can find your plan’s contact information on your plan membership card. Or, you can get your plan’s contact information from a Personalized Search (under General Search), or search by plan name.
The appeals process has 5 levels. If you disagree with the decision made at any level of the process, you can generally go to the next level. At each level, you’ll be given instructions in the decision letter on how to move to the next level of appeal.
• Original Medicare appeals
Filing an appeal if you have Original Medicare
Level 1: Redetermination by the company that handles claims for Medicare
Level 2: Reconsideration by a Qualified Independent Contractor QIC
Level 3: Hearing before an Administrative Law Judge (ALJ)
Level 4: Review by the Medicare Appeals Council (Appeals Council)
Level 5: Judicial review by a federal district court
Medicare Advantage Plan (Health plan) Appeals
If you disagree with your plan’s initial decision, you can file an appeal. The appeals process has 5 levels. If you disagree with the decision made at any level of the process, you can generally go to the next level. At each level, you’ll get instructions in the decision letter on how to move to the next level of appeal.
• Level 1: Reconsideration from your plan
• Level 2: Review by an Independent Review Entity (IRE)
• Level 3: Hearing before an Administrative Law Judge (ALJ)
• Level 4: Review by the Medicare Appeals Council (Appeals Council)
• Level 5: Judicial review by a federal district court
Medicare prescription drug coverage appeals
Your Medicare drug plan will send you a written decision. If you disagree with this decision, you have the right to appeal.
Level 1: Redetermination from your plan
Level 2: Review by an Independent Review Entity (IRE)
Level 3: Hearing before an Administrative Law Judge (ALJ)
Level 4: Review by the Medicare Appeals Council (Appeals Council)
Level 5: Judicial review by a federal district court
Special Needs Plan coverage decision appeal
Your Medicare Special Needs Plan (SNP) must tell you in writing how to appeal. After you file an appeal, the plan will review its original decision. If your plan doesn’t decide in your favor, the appeal is reviewed by an independent organization that works for Medicare, not for the plan.
(To Be Continued)

To choose right Medicare Supplement plan, Medicare Advantage Plan or Medicare Prescription Drug plan, contact Sudhir Mathuria @ 713-771-2900.


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