What to Do When Medicare Says No: Appealing to a Medicare Administrative Contractor

When your care under Medicare Part A or Part B gets denied. You do not have to take “no” for an answer. You have the right to appeal that denial of coverage. The appeals process under Medicare is different than private insurance. This blog describes some of those key differences and will focus on the first level of the appeals process.

What Are the 5 Levels of Medicare Appeals?

If you disagree with Medicare’s decision about how it will cover your care, you have the right to appeal that decision.

There are five levels in the Medicare A/B appeals process:

  1. Redetermination by a Medicare Administrative Contractor (MAC)
  2. Reconsideration by a Qualified Independent Contractor (QIC)
  3. Decision by the Office of Medicare Hearings and Appeals (OMHA)
  4. Review by the Medicare Appeals Council
  5. Judicial Review in Federal District Court

If the claim is denied because there was a clerical or other minor error in the claim, that is not handled through the appeals process. You can work with the provider to fix the mistakes and resubmit the claim to Medicare.

Anyone related to the claim, such as a patient or a health care provider may appeal the denial.

So, if your claim is denied, you can request a “redetermination,” or a review of the claim, by a Medicare Administrative Contractor (MAC).

What is a Medicare Administrative Contractor (MAC)?

A MAC is a private third-party company that the U.S. Centers for Medicare & Medicaid Services (CMS) uses to process certain Medicare claims.

MACs work with providers and CMS to process A/B claims, home health and hospice (HH+H) claims, and durable medical equipment (DME) claims for people who have fee-for-service Medicare (i.e., not a Medicare Advantage plan).

MACs make local coverage determinations, review A/B claims in the first stage appeals process, and review medical records for certain claims.

Different MACs are assigned to specific regions across the U.S. As a result, the MAC that you interact with will depend on where you live. To find out who the current MACs are for each region, refer to the CMS List of MACs.

When Do I Ask a MAC to Review My Medicare Claim?

Once a denial of coverage has been sent to you, you have 120 days from the date you received the denial, to file a redetermination request.

Medicare assumes that you received the denial 5 calendar days after the date on the denial notice, unless there is evidence you didn’t. For example, if you are hospitalized and did not receive the denial letter in the mail until you returned home.

How Do I Ask a MAC to Review My Medicare Claim?

To ask for a review, you must put it in writing, in one of two ways:

  • Option 1: Fill out the form CMS-20027
  • Option 2: Send a written letter that includes:
    • the beneficiary’s name (the patient whose claim was denied)
    • the beneficiary’s Medicare number
    • the specific service(s) and/or item(s) that need to be reviewed
    • the specific date(s) of service
    • the name of the party (e.g., the patient or provider), or the representative of the party (e.g., a caregiver)
    • an explanation of why the MAC’s initial decision was wrong

Send the appeal to the MAC that made the initial claim decision. This information can be found on the initial denial notice. Most MACs also allow electronic submission of appeals through their website.

What Information Should I Include in My Appeal?

It is helpful to include any useful information or documents to support the appeal, including:

  • Notes and/or letters of support from your health care providers
  • Results of tests and procedures related to the care in question
  • Relevant medical literature, professional journals, and studies showing the effectiveness of the care
  • A brief and factual personal statement describing the need for the requested care

Can I appoint another person, such as a lawyer, to represent me in the appeals process?

Yes. A patient or a provider may appoint any individual, including an attorney, to act as their representative during the appeals process. That can happen at any time during the appeals process.

A patient or a provider can appoint a representative by filling out the CMS Appointment of Representative Form (CMS-1696).  A patient or provider can also send the MAC written notice that they will be using a representative in the appeals process. But that notice must follow specific requirements under the law – 42 CFR 405.910.

The representative’s appointment is valid for one year and may be used multiple times to initiate new appeals on behalf of the patient or provider.

When Will a MAC Respond to My Appeal?

A MAC will send its decision about the appeal, within 60 days of receiving your request for review.

It may be reassuring to know that between 2010 to 2014, around 40-50% of Medicare Fee-for-Service appeals were at least partially reversed at the first level of review.

If the MAC dismisses the redetermination request, a patient or provider can move to the second level of review, which is requesting review from a Qualified Independent Contractor (QIC). A QIC is an independent contractor that did not take part in the first level reconsideration decision.

Parties may also request that the MAC vacate the dismissal.

More information on this process can be found on the CMS Medicare Appeals page.

Where Can I Learn More About Medicare?

Navigating the health care system when you have Medicare can feel like a roller coaster and you don’t know what tracks lay ahead. Triage Cancer is here to help with our Medicare & Cancer Resources. On our Resource Page, you can find important information such as Quick Guides to the different parts of Medicare, enrollment periods, financial assistance programs, and more.

About Triage Cancer

Triage Cancer is a national, nonprofit providing free education to people diagnosed with cancer, caregivers, and health care professionals on cancer-related legal and practical issues. Through eventsmaterials, and resources, Triage Cancer is dedicated to helping people move beyond diagnosis.

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Monica Bryant