MEDICARE APPEALS PROCESS
As a Medicare provider, you are responsible for documenting Medicare claims
with all the information that is necessary for the carrier to make coverage
and reimbursement determinations. If information is missing from the claim,
and it is returned or denied, you may resubmit a corrected claim.
REVIEWS
If you disagree with the decision that was made on your claim, you may request
a review of the claim within six (6) months of the initial decision. Requests
for review must include:
A copy of the original claim. Electronic billers should provide a paper
claim copy or a complete description of the service in question;
A copy of the Explanation of Medicare Benefits statement.
A brief explanation of why you want the claim reviewed; and
Any additional information that may not have been available when the claim
was originally submitted.
Example of Appeal Letter from Doctor to Nationwide
Medicare [after care is denied]
Please send your request for a review to:
Nationwide Insurance Enterprise
Medicare Operations
ATTN: Review Department
P.O. Box 57
Columbus, Ohio 43216-0057
HEARINGS
If you disagree with the findings of the review, you may ask for a Medicare
hearing. You should keep in mind that a hearing can be an option only if ALL
of the following requirements are met:
A review was completed within six (6) months of your request.
The amount remaining in controversy is a least $100 (you may combine
claims for two or more patients in order to meet this requirement); and
You accepted assignment or obtained written authorization from the
beneficiary to act on his or her behalf.
When you request a hearing, you must identify the service or claim in question,
send a copy of the Explanation of Medicare Benefits statement and a copy
of the review letter. It would also be helpful for you to provide a copy of
the claim and any evidence relevant to the services at issue.
When you request a Medicare telephone or personal hearing, you will receive a
preliminary hearing decision based on the facts in the file. If you wish to appeal
the decision further, please notify us and we will provide you with a telephone
or personal hearing.
NOTE: Many review and hearing requests can be avoided if all pertinent
information and documentation is included when the claim is originally submitted.
Example of Hearing Request Letter from Doctor to Medicare
[after care is denied]
Please send your request for a hearing to:
Nationwide Insurance Enterprise
Medicare Operations
Hearings Department
P.O. Box 16781
Columbus, Ohio 43216-6781
ADMINISTRATIVE LAW JUDGE HEARING
Must be requested within 60 days of the date of the hearing decision and the
amount in controversy is $500 or more. Please refer to your Medical Policy Manual
for additional details.
OVERPAYMENT
If you receive a request for an overpayment and you disagree with the request,
please follow the instructions below:
If less that $100 in benefits is in question and you believe that an overpayment
has not been made, you have the right to request a review of the overpayment.
Write to us stating why you believe you were not overpaid within six (6) months
of the date of the letter. Send your request for review of the overpayment to:
Nationwide Insurance Enterprise
Medicare Operations
P.O. Box 16621
Columbus, Ohio 43216-6621
A phone number is listed on your overpayment letter if you wish to speak directly
with the person who processed the overpayment request.
If the amount of overpayment is at least $100, your appeal will be handled as a
hearing. Please send a written request within six (6) months of the overpayment
letter to the Hearings Department.
Every effort will be made to conclude the appeal before interest is applied
to the account or the account is offset. However, interest will accrue on the
account and offset will begin 40 days after the initial request for a refund,
if a refund has not been made, regardless of the status of the review or
hearing request. If the overpayment is deemed invalid, any amount withheld
to satisfy the overpayment will be refunded.
For more information on overpayments, or a copy of the Medicare
Overpayment/Refund Form, please see pages 5 and 18 of the June 1997
Medicare Newsletter.
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