Medicare Appeals

1
Medicare Appeals

• How SHIPs Can Help
• Health Assistance Partnership

2
Understand the Situation

• Questions to ask the beneficiary
• What service is Medicare not covering?
• Has he/she received any non-coverage notices?
• If so, review the notice and, if possible, the
  envelope to determine if the notice was delivered
  in a timely manner

3
Decide if There Are Grounds for Appeal

• Look at the applicable laws and regulations about
  the coverage criteria
• Free Online Legal Policy Research at
• http//www.healthassistancepartnership.org/site/P
  ageServer?pagenameTestLegalResearch
• If you believe that the beneficiary met the
  coverage criteria for the service being denied by
  Medicare, you can begin the appeals process

4
Know What Steps to Take and When

• Determine the type of appeals process
• Traditional Medicare
• Medicare Advantage
• National Coverage Determination or Local Medicare
  Review Policy/Local Coverage Determination
• Find out what stage of the appeals process the
  beneficiary is in
• Be careful of deadlines!
• Know when and where to submit an appeal

5
Be Prepared for Anything and Everything

• Keep a supply of appeal forms and Appointment of
  Representative forms so you can help the
  beneficiary fill out all the necessary paperwork
• Available at www.medicare.gov
• Keep copies of all appeals-related documents, and
  mail all paperwork return receipt requested
• Be prepared to help the beneficiary with
  liability and debt collection issues

6
Build the Case

• Understand the medical factors of the coverage
  denial in order to be able to argue that the
  service is reasonable and necessary
• Talk to the beneficiarys health care providers
  until you understand the medical situation
• Follow HIPAA Privacy Guidelines at
  http//www.healthassistancepartnership.org/site/Pa
  geServer?pagenameHIPAAPage
• Research the medical factors

7
Build the Case (cont.)

• Work collaboratively with the beneficiarys
  health care providers to strengthen the case
• Ask for letters of support
• Obtain the beneficiarys medical records relevant
  to the Medicare denial, and review them to see if
  they support the case
• Follow the HIPAA Privacy Guidelines
• Submit relevant medical records as evidence

8
Support the Beneficiary

• Engage in informal advocacy
• Talk with the provider and the carrier about the
  case to see if a formal appeal can be avoided
• Consider attending the appeal with the
  beneficiary, either as the appointed
  representative or for moral support
• Be supportive throughout the entire appeals
  processyou can help alleviate some of the stress

9
HAP Can Help!

• You can do it!
• If you have any questions during the appeals
  process, contact Hilary Dalin at the Health
  Assistance Partnership
• 202.737.6340 (tel)
• hdalin_at_healthassistancepartnership.org