Article: Change in Medicare appeals process
Dear Marci,
I heard that the Medicare appeals process will be changing. Is that true?
-Paul (Victorville, CA)
Dear Paul,
Yes. Starting in 2006 the appeals processes for Part A (hospital and skilled nursing facility services) and Part B (doctor visits, home health and durable medical equipment) will be the same.
Starting January 1, if Medicare denies your first appeal, you can request a "reconsideration" (replacing the Part B "fair hearing"). You will have six months (180 days) to file after Medicare denies your initial appeal. This second level of appeal will be handled by a new group of Medicare contractors called Qualified Independent Contractors (QICs), who will review your medical file to determine if the service in question should be covered. You will not appear in person for the reconsideration.
If the QIC denies coverage, you can continue to appeal through another three levels of review:
Following denial by the QIC, you have 60 days after receiving the decision to request an Administrative Law Judge (ALJ) Hearing. The claim in question must total at least $100.
If the ALJ denies your appeal, you can ask for a Departmental Appeals Board (DAB) Hearing within 60 days of receiving the decision from your ALJ.
If the DAB denies your appeal, you can request a judicial review within 60 days in a federal district court, if the claim in question totals at least $1,000.
You should also be aware of two other important changes to the Medicare appeals process:
Medicare will only send initial determinations of coverage--in the form of a Medicare Summary Notice (MSN)--to the person with Medicare even when Medicare knows that the person has an appointed representative. If you are the appointed representative for someone with Medicare, make sure you are checking the person's mail for the MSNs.
Written notices of appeals decisions must explain how the decision was made; how to request the next level of appeal; and what documents you should submit.
Stay tuned next week to learn about appeals changes for people with Medicare private health plans!
-Marci
----------------------------
Frank Kaiser frank@suddenlysenior.com http://www.suddenlysenior.com
The nationally syndicated column for the 79 million Americans over 50 who've become senior before their time. Read by over one million monthly.
I heard that the Medicare appeals process will be changing. Is that true?
-Paul (Victorville, CA)
Dear Paul,
Yes. Starting in 2006 the appeals processes for Part A (hospital and skilled nursing facility services) and Part B (doctor visits, home health and durable medical equipment) will be the same.
Starting January 1, if Medicare denies your first appeal, you can request a "reconsideration" (replacing the Part B "fair hearing"). You will have six months (180 days) to file after Medicare denies your initial appeal. This second level of appeal will be handled by a new group of Medicare contractors called Qualified Independent Contractors (QICs), who will review your medical file to determine if the service in question should be covered. You will not appear in person for the reconsideration.
If the QIC denies coverage, you can continue to appeal through another three levels of review:
Following denial by the QIC, you have 60 days after receiving the decision to request an Administrative Law Judge (ALJ) Hearing. The claim in question must total at least $100.
If the ALJ denies your appeal, you can ask for a Departmental Appeals Board (DAB) Hearing within 60 days of receiving the decision from your ALJ.
If the DAB denies your appeal, you can request a judicial review within 60 days in a federal district court, if the claim in question totals at least $1,000.
You should also be aware of two other important changes to the Medicare appeals process:
Medicare will only send initial determinations of coverage--in the form of a Medicare Summary Notice (MSN)--to the person with Medicare even when Medicare knows that the person has an appointed representative. If you are the appointed representative for someone with Medicare, make sure you are checking the person's mail for the MSNs.
Written notices of appeals decisions must explain how the decision was made; how to request the next level of appeal; and what documents you should submit.
Stay tuned next week to learn about appeals changes for people with Medicare private health plans!
-Marci
----------------------------
Frank Kaiser frank@suddenlysenior.com http://www.suddenlysenior.com
The nationally syndicated column for the 79 million Americans over 50 who've become senior before their time. Read by over one million monthly.
posted by Kathie Bracy at 10:12 PM
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