Have a Game Plan before You File a Medicare Appeal

By Patricia Barry

Copyright © 2015 AARP

If you’ve gotten a coverage or payment denial from Medicare or your plan, have decided to challenge it, and are now on the brink of working through the appeals process, here’s a general game plan to make the tasks ahead a bit easier:

  • Gather any documents that support your case. These items may include statements from your doctor, pharmacy receipts for drugs you think your plan should cover, and so on, depending on the situation.

  • Put your problem in writing. You may try to get an issue resolved just by calling Medicare or your plan. But if possible, put it in writing and keep a copy so that you have a record. If the matter is urgent, send a fax rather than a letter. Be sure to date all communications.

  • Keep all paperwork. Retain copies of all correspondence relating to your request, complaint, or appeal, including transmission records of faxes and receipts and tracking numbers of anything sent by registered mail. This strategy establishes a paper trail you can use as evidence.

  • Make notes of conversations. Keep track of all the people you talk to at Social Security, Medicare, or your plan. Write down their names and phone numbers; the dates, times, and places where you spoke to them; and the gist of what was said. Having records of your conversations gives you evidence that may prove valuable later on.

  • Try to use the right terminology. Consumer advocates who help people with appeals find that sometimes decisions are delayed or derailed just because the consumer doesn’t talk (or write) the same jargon that officials or plan administrators use.

  • Stick to the deadlines. At every level of appeal, you have a certain time frame (usually 60 days) to file for a review of the previous decision that went against you. If it looks like you’ll miss a deadline for good reason, such as sickness or a family crisis, you can ask for an extension.

  • Don’t give up! If you think you’re right, don’t be put off by a “no” decision or feel intimidated by grand-sounding titles at higher levels of appeal. The title “administrative law judge” may sound formidable, but ALJs more often decide in favor of consumers than officials or plans. If you have a reasonable case, you may well win it.

  • Get help if you need it. You can designate anyone of your choice to help you or act on your behalf in pursuing a complaint or an appeal. At higher levels of appeal or in tricky situations, however, it’s best to seek help from people who are experienced in dealing with appeals on behalf of consumers.