Appeals (Parts C & D)



No one likes to find out that their Medicare claim has been denied. In the last two years, Medicare has imposed more than $10 million in fines and taken other enforcement actions against private plans for overcharging beneficiaries, denying or delaying coverage for prescription drugs, and failing to respond to patients' complaints.

If the appeal or claim analysis requires clinical expertise, the case is sent for review by one of the clinicians on our team (physician, physician's assistant, or registered nurse). If your appeal is denied and your drug is worth at least $160 in 2018, you can choose to appeal to the Council within 60 days of the date on your OMHA level denial letter.

The appeal process is somewhat different depending on the denied item or service and whether you're filing an appeal with Original Medicare or with a Medicare Advantage plan or Prescription Drug Plan. If our answer is yes to part or all of your request, we will authorize or provide the coverage we have agreed to provide within 30 days after we receive the appeal.

If the plan grants your request to expedite the process, you will get a decision within 24 hours of the initial request. If the expedited appeal request 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 our plan denies your appeal for a Part D prescription drug, you will need to choose whether to accept this decision or appeal it to Level 2. The notice we send you denying your Level 1 Appeal will include instructions on how to make a Level 2 Appeal, including who can make the appeal, deadlines you must follow, and How to Appeal Medicare Advantage Denial how to reach the review organization.

Learn more about how Medicare works, coverage options and when to enroll. If your life or health could be at risk by having to wait for a medication approval from your plan, you or your doctor can request an expedited appeal by phone. If we don't cover or pay for your medical benefits or services (Medicare Part C), you can appeal our decision.

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