If you are suggested to get minor procedure or operation by the doctor, but Medicare won’t cover it, you should write a Medicare appeal letter. Sometimes, the denial of coverage might be caused by the simplest things, such as coding error, so you are encouraged to appeal for it.
How Successful Are Medicare Appeals?
Appealing to Medicare denial is considered easy because most people who write will win the denial. According to the data by Medicare Rights Center, 80% of appeals for Medicare Part A and more than 90% of appeal in Part B turned out to be approved.
How Do I File A Successful Medicare Appeal?
To maximize the success of your Medicare appeal letter, follow the tips below:
- Sign the back of your Medicare Summary Notice (MSN) and write message of “Please Review” underneath it, before sending the letter to the appropriate Medicare address.
- Send a letter along to explain the reason for Medicare to cover your claim
- Include supporting document from your doctor or health care provider
- Keep the copies and documentations of Medicare’s denial and your appeal
What Do You Write in An Appeal Letter?
You have to send appeal form that can be downloaded from official site of government’s Medicare. Do include your Medicare Number in the requesting document and keep a copy for yourself all the documents sent as part of appeal.
What Are The 5 Levels of Medicare Appeals?
The Medicare appeals are consisted of five levels:
- Redetermination that’s performed by DME MAC
- Reconsideration that’s performed by Quality Independent Contractor (QIC)
- Review by Administrative Law Judge (ALJ)
- Review by Departmental Appeals Board (DAB)
- Review by Federal Judiciary
Medicare Appeals Sample Letter
Here is an appeal letter sample for Medicare that’s written by a patient:
To Whom It May Concern,
I’m writing this letter to appeal the rejection of Medicare claim with case number of 999888777, with the service dated at December 2, 2020. It was for my knee ligament surgery at Lakewood Hospital, to correct the torn ligament in my right leg when I fall during a regional football match for national championship.
The reason behind my Medical coverage denial is because there is an incorrect data on the modifier code. The insurance biller that works for the hospital writes “R” code to specify which side of my leg that’s going to be treated, but apparently it wasn’t an acceptable code for Medicare system.
The inaccuracy has been corrected by the billing department supervisor at Lakewood Hospital. I have attached with the letter the correct claim, thus I respectfully request for reprocess of medical bill that’s going to be covered by Medicare. I thank you so much in advance for your attention and consideration over this matter.
As mentioned above, there are 5 levels of Medicare appeals. If your appeal isn’t accepted at certain level of process, then you simply have to appeal at the next level. This Medicare appeal letter sample format can be used for each appeal level you’re currently in.