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Appeals if you have a Medicare Advantage Health plan

Requesting an organization determination

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
www.MyMedicarePlanning.com

You have the right to ask your plan to provide or pay for items or services you think should be covered, provided, or continued. This is called an “organization determination.” You, your representative, or your doctor can ask your plan in advance to make sure that the services are covered or after payment of the services is denied.
If you think your health could be seriously harmed by waiting the standard 14 days for a decision, ask your plan for a fast decision. The plan must give you its decision within 72 hours if it determines, or your doctor tells your plan, that waiting for a standard decision may seriously jeopardize your life, health, or ability to regain maximum function.
If the plan won’t cover the items or services you asked for, you’ll get a notice explaining why your plan fully or partially denied your request and instructions on how to appeal your plan’s decision by requesting a reconsideration. If you appeal the plan’s decision, you may want to ask for a copy of your file containing medical and other information about your case. Your plan may charge you for this copy.
What if you disagree with the organization determination?
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.
Medicare health plan appeals – Level 1: Reconsideration
If you disagree with the initial decision (also known as the organization determination) from your plan, you or your representative can ask for a reconsideration (a second look or review). But, you have to ask for a reconsideration within 60 days of the date of the organization determination. If your appeal is for a service you haven’t gotten yet, your doctor can request a reconsideration on your behalf and must notify you about it.
You, your representative, or your doctor must file a written standard or expedited (fast) request, unless your plan allows you to file a request by phone, fax, or email.
Include this information in your written reconsideration request:
• Your name, address, and the Medicare number shown on your Medicare card.
• The items or services for which you’re requesting a reconsideration, the dates of service, and the reason(s) why you’re appealing.
• If you’ve appointed a representative, include the name of your representative and proof of representation.
Include any other information that may help your case. Keep a copy of everything you send to your plan as part of your appeal.
How long your plan takes to respond to your request depends on the type of request:
• Expedited (fast) request—72 hours
• Standard service request—30 days
• Payment request—60 days
You’ll get a fast request if your plan determines, or your doctor tells your plan, that waiting for a standard service decision may seriously jeopardize your:
• Life
• Health
• Ability to regain maximum function
The time to complete standard and fast service requests may be extended by up to 14 days in some cases. For example, your plan needs more information from a non-contract provider to make a decision about the case, and the extension is in your best interest. Your plan will notify you in writing if it decided to take an extension. Your plan will notify you of the reasons for the delay and inform you of your right to file an expedited (fast) grievance if you disagree with the plan’s decision to take an extension.
If the plan decides against you (fully or partially), your appeal is automatically sent to level 2.. (To Be Continued)

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


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