Age Spots: This (Medicare) Appeal is Bananas

Do you know you can appeal most decisions in Medicare? If you disagree with a payment or coverage decision Medicare has made, you have the right to appeal the decision. Each part of Medicare handles appeals differently.

Original Medicare Part A and B appeals can be made using the Medicare Summary Notice (MSN) or your MyMedicare account. If Medicare denies payment for a service or item, you can circle the denied claim on your MSN, fill out the information on the last page and mail a copy of the MSN and supporting documents to the address listed. You have to make your appeal within 120 days from the date listed on the MSN. You can also get a Medicare Redetermination Request Form (CMS-20027) to fill out and mail back. It could be helpful to contact the provider of the denied claim to see if it was billed correctly or to get documentation that would help in the appeal.

The appeals process has five levels, and if you disagree with the decision made at a level, you can generally go to the next level. You will get a decision letter, and that will have instructions on how to appeal to the next level.

If you are in a Medicare Advantage Plan, you must appeal through your plan. Follow the directions in the denial letter; these appeals need to be made within 60 days of the denial. If you miss that deadline, you must give reasons for filing late.

Medicare Prescription Drug Plans send out an Evidence of Coverage that will show your costs under the plan: premium, deductible and co-pays. Beneficiaries have the right to ask the drug plan to provide or pay for a medication you think should be covered. You can appeal if you disagree with the decision. Contact the plan directly to start the appeal process. You can also ask for an expedited decision if your health is at risk by waiting. Expedited decisions are made within 24 hours. Standard decisions are made within 72 hours, and payment requests can take up to 14 calendar days.

If you need to make an appeal, make sure to put your Medicare or identification number on all documents, and make copies of everything you send.

One issue we get questions about is if someone is being discharged from a hospital "too early;" perhaps they are in severe pain and need more monitoring. You can contact the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). In Missouri, that is KEPRO, (855) 408-8557. You can ask for help appealing the discharge. You can ask for a "fast appeal" before your discharge, and the decision should be made quickly.

You have the right under Medicare to get understandable information about Medicare to help you make health care decisions, including:

·What is covered

·What Medicare pays

·How much you have to pay

·What to do if you want to file a complaint or appeal

Know your rights and take the steps needed to protect yourself.

Remember, it is currently Open Enrollment for the Medicare prescription drug plans and the Medicare Advantage Plans until Dec. 7. If you need to look at your plan or if you have questions, please call Aging Matters at (800) 392-8771.

~Jackie Dover is public information director at Aging Matters.