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What Appeals Process Exists for Denied Medicare Home Health Care Claims?
Date Updated: December 10, 2024
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A standard appeals process exists for denied Medicare home health care claims. Individuals must follow guidelines and provide required documentation within strict deadlines to appeal any Medicare decision, including refusals to cover or continue to fund home health care services. Several organizations provide advice and assistance with appeals.
Initial Appeal Steps
Diverse reasons result in the denial of a Medicare home health claim, including missing documentation or Medicare not considering services medically essential. Medicare Summary Notices (MSN) explain reasons for refusal. Individuals get these every three months while receiving Medicare funding and after a denied initial or continuing claim. After reviewing the MSN, gather any evidence, such as medical records, prescriptions and caregivers’ notes, that supports their need for home health care. People can also call 1-800-MEDICARE for details of denied claims and appeals guidance.
People must file an appeal within 120 days of receiving an MSN. Appeals must be on a standard form called the Redetermination Request Form (CMS-20027). The MSN details where to post completed appeals forms.
Process for a Second-Stage Appeal
After considering evidence, Medicare might still deny a claim. In this case, individuals can submit a further appeal to a Qualified Independent Contractor within 180 days of the first appeal denial. They should use a Reconsideration Request Form (CMS-20033) and include evidence they believe supports their case. Claimants can seek support and information from the agencies mentioned above.
Procedures for Subsequent Appeals
If the decision of the second appeal remains unfavorable, individuals still have other avenues of appeal left. Successive appeals, in order, include:
- Level 3 appeal: Individuals have 60 days to request a legal hearing in front of an Administrative Law Judge. They should write a letter requesting a hearing or complete a Request for Hearing by an Administrative Law Judge Form (OMHA-100).
- Level 4 appeal: People can submit a further appeal in writing to the Medicare Appeals Council within 60 days.
Level 5 appeal: The final stage of the appeals process involves bringing a lawsuit to the local federal district court. Individuals must start their claim within 60 days of receiving a denied appeal from the Medicare Appeals Council.