How to appeal the refusal of a Medicare claim

The beneficiaries of Medicare that they received a negative response to their claims can appeal through a process tripartite. In each of them, you have the opportunity to present the reasons why you consider that your claim should be approved.

The third appeal takes place before an administrative judge, who checks out your claims history and makes a final decision, but only in case of failure in the first two appeals. You have 180 days from the date of your first Medicare claim denial to appeal the decision, but the sooner you present your first appeal, you will receive faster results.

You will need to

  • Form CMS-20027
  • Form CMS-20033
  • Form CMS 20034 a/b
  • Form CMS-1696 (optional)
  • Form CMS-20031 (optional)
  • Letter of denial of Medicare claim
  • Information for Medicare claims
  • Medicare insurance policy
  • Medical records relating to the claim

Instructions

  1. Check your letter of denial of Medicaid claim to determine the cause of the refusal. Medicare typically, quotes your insurance policy for articles explaining the reason for the denial. Use a sheet of paper to record every reason for the denial and the corresponding sections of your policy referred to in the letter of refusal.
  2. Carefully check your current Medicare plan and compare it with the motif that appears in the negative. If your claim is explicitly excluded from the coverage of your insurance policy, then you cannot appeal the decision of Medicare and you are fully responsible for the costs of the claim. If your claim is not explicitly excluded or your claim is covered by your plan, then takes note of the applicable items in your insurance policy to support your opinion that Medicare must approve your claim.
  3. Get the form CMS-20027 (Revision request form of Medicare). You can request it personally in your local Medicare Office or contact the representative of Medicare so that I send it to you by mail free of charge. You can also download and print this form directly from the Medicare web site. You must keep in mind that if a family member or friend is taking your claims to Medicare for you, then also must obtain or download the form CMS-1696 (appointment of a representative) and the form CMS-20031 (transfer of rights of appeal), that you and your representative must fill out and sign. This enables your representative acting on your behalf and handles your appeal of refusal by Medicare for you. Complete and present these forms along with your appeal.
  4. Complete the CMS-20027 form with your personal details, your account number for Medicare and information relating to the claim that was denied to you. In line 5, you must indicate the reason why you dont agree with the refusal of Medicare and quote articles from your insurance policy that you already revisits previously. If you need additional space to present your case, use another sheet of paper and place the back of the form CMS 20027. Signing the form at the bottom when youre done.
  5. Get a copy of the signed form CMS-20027 and save it to your personal files. Send by mail or fax the original form already signed to the same representative of Medicare that rejected your claim. If you win the appeal, Medicare will pay the amount of your claim, and no additional action is required. If your appeal is rejected, you can then appeal the decision twice more using other two forms.
  6. And complete the form CMS-20033 (reconsideration request form of Medicare) only if your first appeal was rejected. You have 180 days from the date of your first appeal to present it. Follow the same steps described above to complete and submit the form, but present it to the qualified independent contractor (QIC, for its acronym in English) assigned to your case. The representative of Medicare that handled your first appeal can provide you with the contact details of the QIC. If you win the appeal at this level, Medicare will pay your claim and there is nothing more that you should do. If this second appeal is denied, you can appeal once more and request an administrative hearing to argue your case.
  7. And complete the form CMS-20034 a/b (request for Medicare hearing) only if your second appeal is rejected and the total amount of your claim is at least US$ 120. You have 60 days from the date of your second appeal to present it. Follow once again the same steps to complete and submit the form to your representative Medicare. This should set a date for the hearing which you (and if necessary, your personal representative) must attend. Take with you copies of the original letter of denial of the claim, your previous requests for appeal, your insurance policy, medical records related to the request and additional documents that support your case. The judge must review the previous appeals and make a final decision. If you lose your appeal at the hearing, Medicare will not pay your claim and now cannot do anything more.