Appeals (Parts C & D)
The Arizona Supreme Court, in an interesting case involving a Medicare-related coverage dispute between a Medicare Advantage plan administrator, United Behavioral Health (UBH), and two inpatient psychiatric care providers, held that the Medicare administrative appeals process preempts the arbitration language contained in the UBH provider agreements. For amounts of at least $1,400, the final level of appeal is judicial review in U.S. district court. Enrollment in Independence Medicare Advantage plans depends on contract renewal. You or your representative can follow the instructions found in the Level 4 review decision to file a Level 5.
WASHINGTON — Medicare Advantage plans, the popular private-insurance alternative to the traditional Medicare program, have been improperly denying many medical claims to patients and physicians alike, federal investigators say in a new report. There are five levels to Medicare's appeals process.
When you appeal at the hearing level, you will have a much better shot at a quick response time if you clearly mark your appeal and the envelope you send it in as a "Beneficiary Appeal" to distinguish it from provider appeals, said Terry Berthelot, a senior attorney at the Center for Medicare Advocacy.
The How to Appeal Medicare Advantage Denial process for coverage decisions and making appeals deals with problems related to your benefits and coverage for medical services, including problems related to payment. On the basis of the sample, the OIG estimated that Etheredge received $169,737 in unallowable Medicare payments for CYs 2014 and 2015.
After you file the appeal, the plan will reconsider its decision. In 2015 alone, CMS cited over one-half of 140 MAO contracts (56 percent) for inappropriately denying payment and care requests. You should receive a written notice from your plan stating that it is not covering your health service or item.
The Independent Review Entity is hired by Medicare and will conduct a new and independent on-the-record review of your claim. Additional denials were overturned by independent reviewers at higher levels of the appeals process. At 800-316-3107 (TTY 800-899-2114), 24 hours a day seven days a week, if you would like to request a coverage determination.