Favorite Links: NPI Search

Appeals

Once you receive a denial from Medicare, your options do not end. Medicare always allows you the right to appeal a denial. If you have examined your claim and are dissatisfied with the payment, or lack thereof, that you received or you feel that the DMERC made a mistake in processing (which does happen!), you may begin the appeal process.

In some cases, your first step may be as simple as a phone call to the customer service center at your DMERC. They can be helpful in determining why a claim was denied, as some denial codes are ambiguous. However, don't expect the issue to be resolved with this phone call! Merely use this call for information gathering. The representative can help you with coverage issues, policy information and general information about the claim.

There are five levels of appeal that are available in getting a claim resolved, but they rarely go beyond the first two. The first level is called a review and is relatively easy. Once you have researched the claim and have documentation to prove why you think it should have been paid, you may submit a request in writing to the DMERC. This request must be submitted within six months of the initial denial. A staff member that did not originally process the claim will review the claim using the documentation that you have included. In submitting your written request, you must make sure to include the following information: your name, address and NSC number, the patient's name, HICN, date of service in question, the reason you are questioning the decision, the CCN (claim control number) and any more documentation that you have to prove your point. The DMERC will respond to you within 45 days by either reprocessing the claim for payment, or by explaining to you that the claim will remain denied and why.

If your review has been denied, you have another option. If it is for an amount over $100, you make request a fair hearing (you may combine claims from the same beneficiary to reach the $100 mark). The only way a fair hearing can be initiated is if a review has already been done; so if you do not have record of a review, do not request a fair hearing. You must file a request for a fair hearing within six months of the review. There are three different kinds of fair hearings: on-the-record, telephone and in person. The on-the-record hearing will be conducted based on the facts that are in the file and any additional documentation. The telephone and in person hearings involve the claimant presenting oral arguments. The request should be for a particular type of hearing and should be in writing and have all important documentation attached. The response time for a fair hearing is a little bit longer; expect up to 120 days.

If your fair hearing is denied, and you still feel that you have proof that your claim should have been paid, you have three more steps that you can take. The first would be an ALJ (Administrative Law Judge), but you must have more than $500 in question. Next is an Appeals/Council and lastly, a Judicial Review, where you must have over $1000 in question.

This site property of Tech-Savvy Consulting Incorporated.
Use of this web site constitutes acceptance of the HMEdata.com User Agreement and Privacy Policy.
Your browser must accept cookies for some portions of this site to function properly.