Steps to Take When Appealing a Denied Medicare Claim
(Adopted from a table that appeared in the Wall St Journal)
(10/26/12)- "Return your Medicare Summary Notice-which shows any denied claims-to the appeals address listed on the notice for a "redetermination"." Circle the claim you wish to appeal, write "Please review, " sign the back and include any supporting documents (e.g., a letter from your doctor). Must be filed within 120 days of receiving the Medicare summary notice.
If the appeal is denied, request a review by an independent contractor. Fill out a Medicare Reconsideration Request Form (CMS Form No.20033, available at cms.gov or at 1-800-MEDICARE). Must be filed within 180days of receiving the redetermination ruling.
If the reconsideration is denied, (and as long as the amount in question is at least $130), request a hearing before an administrative law judge CMS Form No.20034 A/B. Typically occurs by phone or video conference. Must be filed within 60 days of receiving the reconsideration ruling.
If you disagree with the judge's ruling, you can appeal the decision to the Medicare Appeals Council (Form DABA-101, available at hhs.gov). Must be filed within 60 days of receiving the judge's ruling.
If you disagree with the Council's decision, and if the amount in question is at least $1,350, you can request judicial review by a U.S. District Court. Must be filed within 60 days of the council's decision."
FOR AN INFORMATIVE AND PERSONAL ARTICLE ON PRACTICAL SUGGESTIONS WHEN SELECTING A NURSING HOME SEE OUR ARTICLE "How to Select a Nursing Home
By Allan Rubin
updated October 26, 2012
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