Medicare appeals are actions that you may choose to take if your request for medical coverage or reimbursement is denied by your Medicare provider. If you receive a Medicare denial letter and disagree with a payment or coverage decision, then you may submit documentation from your doctor or medical supplier along with your request for an appeal, as doing so may help to strengthen your case for medical coverage or financial reimbursement. If you need assistance, then the local office of your State Health Insurance Assistance Program (SHIP) can help you to begin the appeals process.

Moreover, Kepro and Livanta appeal HelpLines are available to you and other beneficiaries who wish to request a fast appeal. Both companies work under a contract with the Centers for Medicare and Medicaid Services (CMS), helping to improve the quality of care that Medicare beneficiaries receive. To learn more about Livanta and Kepro appeals as well as explore the process of requesting an appeal, review the information below.

Learn About the Medicare Appeals Process

You may request a Medicare appeal if you disagree with a payment or coverage decision that was made under Original Medicare, a Prescription Drug Plan or another type of Medicare health plan. Typically, you may appeal a Medicare denial if Medicare refuses to pay for a new service or prescription drug that you believe should be covered or Medicare stops paying for a drug or service you already receive. You may also choose to request an appeal if you believe that the amount you owe for a service or prescription medication should be lower than it is.

To appeal Medicare denials or other coverage decisions that you disagree with, you must begin the process by obtaining supporting documentation from your medical provider. Then, you must keep copies of these documents for your personal records. If you wish to obtain additional information about your rights before you request the appeal, then contact your Medicare plan provider. You can find this contact information on your Medicare card.

Moreover, the process of requesting an appeal varies depending on the type of Medicare coverage you receive. To request Original Medicare appeals, the process consists of the following five levels:

1. A redetermination by your state’s Medicare Administrative Contractor (MAC)
2. A reconsideration by a Qualified Independent Contractor (QIC)
3. A hearing before the Office of Medicare Hearings and Appeals (an Administrative Law Judge)
4. A review by the Appeals Council
5. A judicial review in federal district court

If you disagree with a determination that was made at any level, then you may choose to move on to the next level in the appeals process. However, you can only move onto the fifth level if your case amounts to at least $1,630.

Discover the Medicare Appeals Process for Prescription Drug Plans

If you wish to request a Medicare appeal when your prescription drug plan refuses to pay for a medication, then you must first obtain a written determination from your provider. Then, you can contact your drug plan provider to request a redetermination within 60 days of receiving the Medicare denial letter. Some plans may allow you to file the appeal by telephone, but others will require you to submit your appeal in writing.

If you disagree with the drug plan provider’s decision after you request a redetermination, then you may proceed to the second level of the appeals process. The second level consists of a reconsideration by an Independent Review Entity (IRE). Download this guide on Medicare to learn more about the program and getting the right coverage.

Learn About the Kepro and Livanta Appeals

While the standard Medicare appeals process consists of five levels, the CMS offers you the right to a fast appeal if you believe that your covered services are ending prematurely. For instance, you may wish to request a fast CMS appeal process if a hospital or rehabilitation center tries to discharge you before you are ready or you feel that you are too sick to leave. Before the hospital discharges you, you will receive a letter from Medicare that provides you with detailed information about the steps you can take to request a fast appeal. In order to request a fast Medicare appeal, you must ask for this notice if your medical provider does not give it to you.

Once you receive the notice of your upcoming discharge, you may contact the Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) that serves the state in which you live. These companies include Kepro and Livanta. Then, you must contact your state’s Kepro or Livanta Appeal HelpLine to begin the process of requesting a fast appeal. If you are staying in a hospital when you request a fast appeal, then you can typically stay there at no additional charge until your local BFCC-QIO reviews your case and reaches a decision.

Note: To notify you of your Kepro or Livanta Appeal status, your state’s BFCC-QIO will contact you and send you a letter as soon as it reaches a determination.

Find Out How to Request a Medicare Part B Late Enrollment Penalty Appeal

Another type of Medicare appeal may be of interest to you if you fail to sign up for Part B medical coverage when you first meet the Medicare requirements. If you do not sign up for Medicare Part B coverage in a timely manner, then you may need to pay a monthly penalty fee when you do enroll unless you choose to request an appeal. Your local SHIP office can help you to determine whether a request for an appeal is right for you.

In some cases, you may need to pay another type of penalty fee if you go without prescription drug coverage for a certain amount of time. However, if you do not agree with this determination, then you may choose to request an appeal within 60 days of receiving the penalty notification.

To begin the CMS appeal process for prescription drug coverage, you simply need to obtain a reconsideration form from your Medicare drug plan provider. When requesting the appeal, you will also need to provide evidence that supports your claim, such as proof of your previous prescription drug policy. For more details about Medicare, you need to know, download this free guide.