- A request for a healthcare service, supply, item, or prescription drug that the beneficiary believes they should be able to get.
- A request for payment for a healthcare service, supply, item, or prescription drug the beneficiary already got.
- A request to change the amount the beneficiary must pay for a healthcare service, supply, item, or prescription drug.
A beneficiary can also appeal if Medicare or their plan stops providing or paying for all or part of a service, supply, item, or prescription drug the beneficiary believes they still need.
- If a beneficiary is enrolled in Medicare and disagrees with a coverage or payment decision made by their Medicare plan, the beneficiary has the right to appeal that decision. The Medicare appeal process is a way for the beneficiary to have a case reviewed by a higher level of decision-making authority within their plan or by an independent organization.
- There are four levels of appeal within the Medicare system:
- Reconsideration: If a beneficiary disagrees with the decision made at the redetermination level, they can request a reconsideration. This level of appeal is handled by an independent organization known as a Qualified Independent Contractor (QIC).
- Redetermination: This is the first level of appeal and is handled by a beneficiary’s Medicare plan. If the beneficiary disagrees with a coverage or payment decision made by their plan, they can request a redetermination by filling out a Medicare claim appeal form and submitting it to their plan.
- Administrative Law Judge (ALJ) hearing: If a beneficiary disagrees with the decision made at the reconsideration level, they can request an ALJ hearing. This level of appeal is handled by an ALJ who is independent of the Medicare system.
- Medicare Appeals Council (MAC) review: If a beneficiary disagrees with the decision made at the ALJ hearing, they can request a review by the MAC. The MAC is a group of ALJs who review decisions made at the ALJ level.
- It is important to note that the Medicare appeal process can be complex and time-consuming, and it is recommended that the beneficiary seeks the assistance of a healthcare professional or advocate if they are considering appealing a coverage or payment decision. It is also important to be aware that there are deadlines for requesting each level of appeal, so it is important to act promptly if they wish to appeal a decision.
