If your Part C Medicare Advantage claim is denied - for people in a Medicare Advantage plan
Overview
If you are unhappy with a decision made by your Medicare Advantage (MA) plan about your health care, you have 4 options:
- You can argue your case through the appeals process.
- You can request an expedited appeal, if appropriate.
- You can request a fast-track appeal, if appropriate.
- You can file a complaint through the internal grievance procedure.
You can also appoint someone else – a family member, friend, caregiver or doctor – to be your representative in an appeal or complaint.
Your MA plan is required to include this information on the appeals and grievance processes in its membership materials, and give this information to each enrollee.
Note that if you are unhappy with a decision made by your MA plan about prescription drugs, there is a separate appeals process. See our section on Medicare Prescription Drug Coverage Appeals.
Common appeals situations
Under the following situations, you can appeal your MA plan’s decisions:
- If you have been denied payment for using medical services received outside the MA plan in an emergency or urgent care situation, or for using other medical services when you couldn't get the care you needed within the MA plan.
- If your MA plan refused to give you or failed to give you treatment in a timely manner that you feel would otherwise be covered by Medicare. (In some cases, an expedited appeal may be in order.)
- If your MA plan discontinues services you believe are still medically necessary.
Option 1: Appeals process
Organization Determination. If you asked your MA plan to provide or pay for a service or item that you think should be covered or continued, the plan’s response or decision is called an organization determination. If the plan decides not to cover or continue a service or item, it must inform you in writing and include:
- reason(s) for denying the service or item, and
- how to appeal the organization determination.
If a written notice is not given within 14 calendar days for a requested service, or within 30 days for a requested payment, you may treat the situation as a denial and request reconsideration by the plan, which is the first step in the appeals process (see below).
The Medicare Advantage appeals process can include up to 5 steps.
Step 1. Reconsideration by Plan
If you are not satisfied with the plan's decision, you have 60 days to request a Reconsideration in writing.
- The MA plan must issue a decision on the Reconsideration request within 30 days (for service issues) or 60 days (for payment issues).
- If the MA plan does not reverse its denial, the appeal must be forwarded to an Independent Review Entity (IRE) within 24 hours by the MA plan.
Step 2: Independent Review Entity (IRE)
The IRE is a company that contracts with Medicare. It is called Maximus CHDR (Center for Health Dispute Resolution). Timeframes for review are outlined in a contract between Maximus and Medicare. The current timeframes for conducting the external review are:
- Expedited reviews: 72 hours to 17 days
- Service denials: 30 to 44 days
- Payment denials: 30 to 60 days
Step 3. Administrative Law Judge (ALJ) Review
If your claim is denied by the Maximus CHDR review, you have the right to a fair hearing before an administrative law judge (ALJ) if the amount in dispute is at least $120 (in 2008). You have 60 days from the date of the IRE decision to file a request for an ALJ hearing. The ALJ has 90 days to issue a decision, but the timeframe can be extended for various reasons, such as submission of new evidence or if you request an in-person hearing. ALJ hearings take place within the federal Department of Health and Human Services (DHHS), which has only four offices nationwide that house ALJs. So ALJ hearings will be held by:
- Video teleconference;
- Telephone; or
- In-person (at the ALJ's discretion, if you can show "good cause" as to why the hearing should be in person).
Step 4. Medicare Appeals Council (MAC)
If the ALJ decides against you and you want to continue the appeals process, you have 60 days to request a MAC review. Most MAC reviews will not be in person. Instead, the MAC will review the relevant documents and issue a decision. The MAC has 90 days to issue a decision, but this time period can be delayed for several reasons.
Step 5. Federal Court
If the MAC rules against you and the amount in dispute is at least $1,180 (in 2008), you can file a lawsuit in federal district court within 60 days. You will probably need legal assistance, and the process will likely be time-consuming.
Note: You should consider seeking legal advice before appealing to an administrative law judge, the Medicare Appeals Council, or federal court.
Option 2: Medicare Advantage expedited appeals process
An "expedited appeal" is a faster way to have your request for services addressed. Many medical conditions require immediate action when a service has been denied or terminated. Patients whose health or life would be at risk of deterioration or death are good candidates for an expedited appeal.
When a doctor requests an expedited appeal, the MA plan must review the case within 72 hours. This doctor does not need to be the one assigned to the patient (primary care physician), nor does the doctor need to be a member of the patient's MA plan.
If the expedited appeal is made by the patient or patient's advocate, the MA plan will review the request and either grant or deny it. If approved, the appeal occurs within 72 hours. If denied, the appeal goes through the standard 14-day appeal process.
Option 3: Fast-track appeals process
If you feel you are being discharged from the hospital before you are ready, you have the right to request a fast track appeal through California's Quality Improvement Organization (QIO), Lumetra. You also have the right to request a fast track appeal through Lumetra if your Medicare Advantage coverage for services in a skilled nursing facility, home health care agency or a comprehensive rehabilitation facility are about to end. This appeal differs from an expedited appeal in that an outside organization, California's QIO, Lumetra, reviews your appeal instead of the HMO.
At least 2 days before your coverage ends for a given service, your MA plan must give you and your provider an "Important Message of Non-Coverage" notice. This notice must state:
- the date Medicare coverage will end (this date, which will be clearly typed at the top of the page, must be at least 2 days after the date you receive the notice);
- the date you will be responsible for the cost of your care (this date must also be at least two days after the date you receive the notice);
- how to get more information about why the MA plan is terminating your coverage for this service; and
- how to exercise your right to use this fast track appeals process.
Your MA plan must also send you a more detailed notice of non-coverage that explains specifically why it discontinued your coverage and lists the relevant Medicare rule that justifies that decision. You will not receive this notice until after you request an appeal.
To make a fast-track appeal, follow the instructions on the Important Message notice and request an appeal by noon on the following day (the day after you receive the notice). You can also call Lumetra at 1-800-841-1602 or 1-800-881-5980 (TDD-hearing impaired).
Once you request a fast-track appeal, your MA plan is required to send your medical records to Lumetra within 1 day. Lumetra must then decide on the fast-track appeal by the day after it receives the medical records from your MA plan. If Lumetra agrees with you, it may set a new service termination date, or have your MA plan give you another Important Message notice when it decides to discontinue coverage for services in the future. If Lumetra agrees with the MA plan, you will be responsible for the cost of your care starting the day Lumetra reaches its decision.
Option 4: Grievances
Medicare Advantage plans are required to have internal grievance procedures, which apply only when the appeals procedures do not.
You may file a grievance concerning non-appealable issues at any time. You may also file a grievance on a denied request for an expedited appeal. The grievance process addresses complaints outside of the formal appeals process.
Grievance procedures can be used in the following instances:
- Complaints about services in an optional supplement benefit package
- Complaints regarding issues such as waiting times, physician behavior and demeanor, adequacy of facilities, and other member concerns
- Involuntary disenrollment situations
The MA plan is required to have written procedures in place that inform all members about the grievance process — including specific timeframes for each step and instructions for how to file a grievance.
Grievances must be transmitted in a timely manner to the appropriate decision-making levels within the MA plan. The MA plan must promptly take appropriate action, including a full investigation, if necessary. The person filing the complaint must be notified in writing of the results of the investigation.
In addition to filing appeals or grievances, you can also complain to your Quality Improvement Organization (QIO), if a quality-of-care issue is involved. QIOs are groups of practicing doctors and other health care professionals who are under contract with Medicare to review the care provided to Medicare patients. In California, the QIO is Lumetra: 1-800-841-1602.