If you're a fee-for-service Medicare beneficiary and you've been denied a claim for some reason, you may be entitled to a second opinion.
The first step is to write a short letter, including your Medicare number and the claim control number on the explanation of benefits form. You are free to state your reasons for the appeal, but it's not required. Enclose documents and medical records that support your case. Retain copies for your records.If you aren't satisfied with the review decision, you can go to the next level:
- If it's a Part A (the part of Medicare that covers hospital costs) reconsideration decision and at least $100 is at issue, you have 60 days to file a request for an administrative law judge (ALJ) review. After the ALJ decision, you have 60 days to file to the Appeals Council.
Your last recourse is federal district court. To go on to this level, you must file your appeal within 60 days of the Appeals Council decision and at least $1,000 must be in dispute.
- If it's a Part B review and $100 or more is in dispute, you have six months from the date of the review decision to ask for a "fair hearing.
The next step is to ask for an ALJ hearing. At least $500 must be at stake and the appeal must be filed within 60 days of the fair-hearing decision.
Claims going to federal court must involve at least $1,000. You probably don't need a lawyer, but you should get help from your doctor, says Joe Baker, a lawyer with the Medicare Rights Center.