Monday, May 24, 2010

What Is an Appeal? and how to appeal the denial?

What Is an Appeal?

An appeal is the action you can take if you disagree with a coverage or payment decision made by Medicare or your Medicare plan.

You can appeal if Medicare or your plan denies one of the following:

A request for a health care service, supply, or prescription that
You think you should be able to get
A request for payment for health care services or supplies or a
Prescription drug you already got that was denied
A request to change the amount you must pay for a prescription  drug
You can also appeal if Medicare or your plan stops providing or paying for all or part of an item or service you think you still need.

If you decide to file an appeal, ask your doctor or other health care provider or supplier for any information that may help your case.

How to File an Appeal

How you file an appeal depends on the type of Medicare coverage you have:

If you have a Medicare health plan, look at your plan materials, call your plan, or visit to view the booklet, “Your Medicare Rights and Protections.”

If you have a Medicare Prescription Drug Plan, look at your plan materials, ■■call your plan, or look on pages 90–91 to learn how to file an appeal.

If you have Original Medicare, do the following to file an appeal:

Get the Medicare Summary Notice (MSN) that shows the item or  service you are appealing. Your MSN is the statement you get every 3 months that lists all the services billed to Medicare and tells you if Medicare paid for the services.

Circle the item(s) you disagree with on the MSN, and write an explanation on the MSN of why you disagree.Sign, write your telephone number, and provide your Medicare number on the MSN. Keep a copy for your records.

Send the MSN, or a copy, to the Medicare contractor’s address listed 4. on the MSN. You can also send any additional information you may have about your appeal.

You must file the appeal within 120 days of the date you get the MSN. If you want to file an appeal, make sure you read your MSN carefully, and follow the instructions. You can also use CMS Form 20027, and file it with the Medicare contractor at the address listed on the MSN. To view or print this form, visit

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