Appeals & Grievances Process

I have been a health insurance broker for over a decade and every day I read more and more "horror" stories that are posted on the Internet regarding health insurance companies not paying claims, refusing to cover specific illnesses and physicians not getting reimbursed for medical services. The appeals process is a formal process with detailed procedures and important deadlines. These appeals are in addition to the non-contracting provider payment dispute process. For Keystone 65 HMO members, the plan requires prior authorization (approval in advance) of certain covered medical services.

America's Health Insurance Plans (AHIP), an insurance trade association, defended Advantage plans, noting that the OIG report found overall denial rates of only 4 percent for prior authorization requests and 8 percent for payment requests - meaning that nearly all claims are approved.

If we agree with our original determination, the appeal will automatically be sent to Maximus Federal Services for review. One of the principles behind MA is that plans could save Medicare money by reducing utilization before services are rendered, in contrast to Medicare's familiar pay-and-chase” model.

Appealing a Part C denial: Part C plans, also known as Medicare Advantage plans, are provided by private insurance companies. You also may file an appeal if you believe that Medicare has failed to pay the proper amount for services or if coverage has been denied for a particular service.

If a Medicare health plan denies service or payment, in whole or in part, the plan is required to provide the enrollee with How to Appeal Medicare Advantage Denial a written notice of its determination. And, even with such a small fraction of their members appealing, Medicare Advantage plans overturned 532,000 denials of care or payment-three out of four of these denials-over the two-year period.

You may also ask for a Fast Appeal for prescription drugs, if waiting for a Standard Appeal could seriously harm your health or your ability to function. But many similarly frustrated older adults aren't sure how to appeal Medicare drug plan denials. Look for a Medicare Redetermination Notice within 60 days after the Medicare Administrative Contractor (MAC) gets your redetermination request.