Medicare Appeal Denial Part A

Answer 1

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Medicare consists of two parts. Part A (hospital insurance) covers hospital care, limited post-hospital skilled nursing facility care, part-time home health services, and hospice care. If you are 65 years old or over, you can receive Medicare Part A insurance without having to pay a premium if you are currently receiving or eligible to receive but have not yet filed for either Social Security or Railroad Retirement benefits or if you or your spouse had Medicare-covered employment by the government. If you are under 65, you can receive Medicare Part A insurance without having to pay a premium if you have received either Social Security or Railroad Retirement benefits for twenty-four (24) months or if you are a kidney transplant or kidney dialysis patient.

Deductibles and coinsurance amounts must be paid by the Medicare beneficiary.

Medicare measures the amount of covered hospital care and skilled nursing care in benefit periods. A benefit period begins on the first day you receive care and terminates after you have been out of the hospital or skilled nursing facility and have not received care in any other facility for 60 consecutive days. Medicare does not limit the number of benefit periods any one beneficiary can have. Beneficiaries are entitled to a lifetime reserve of 150 days of in-patient services.

Medicare Part A covers 90 days of inpatient hospital care for each benefit period. If you need skilled nursing or rehabilitative services after a hospital stay and meet certain conditions, Medicare Part A helps pay for up to 100 days in a participating skilled nursing facility for each benefit period. For the first 20 days in a participating skilled nursing facility, Medicare pays for all approved charges. You must pay a coinsurance amount for the 21st day through the 100th day.

If you qualify, Medicare pays for all approved costs of covered home health care services. You will have to pay a 20% coinsurance charge for certain medical equipment, such as a wheelchair or a walker.

The terminally ill Medicare beneficiaries who select the hospice care benefit are not required to pay deductibles but are required to pay a limited amount for certain drugs and inpatient respite care.

This document provides a letter to request that Medicare reconsider its decision on a Part A claim. Providers of Part A services submit claims for their services directly to Medicare. The provider will charge you for any part of the Part A deductible that you have not met and any coinsurance payments that you owe.

You will receive a determination explaining the decision that Medicare has made on the claim. (If you have received a "Notice of Noncoverage," this is not an official determination. Ask your provider to submit your claim so that you can receive a determination from Medicare explaining the noncoverage of the claim.)

If you disagree with a decision on the amount Medicare will pay on a claim or whether services you received are covered by Medicare, you have 60 days after receipt of the initial determination, which is presumed to be five days after the date of the initial determination notice, to request a reconsideration. (There are procedures to establish good cause for filing a late request for reconsideration.) The first step in the appeal process is to ask for a "reconsideration" of the decision. The initial determination contains the address and phone number of the organization to contact about your appeal.

You will receive a written response of the reconsideration that explains the reasons for the decision. If you disagree with the reconsideration of the decision, AND if the amount in question is $100 or more, then you have 60 days from the date you receive the reconsideration notice to request a hearing with an Administrative Law Judge.

If you are considering such a request, you should contact your local social security office or your personal attorney regarding your appeal as soon as possible. Additional appeals are available and it is important that you carefully observe the time limit for requesting each appeal step.

You may also be able to request a reconsideration by telephone. Contact your local social security office for more information.