A recent investigation into Medicare Advantage participants exposed that 13% had experienced a refusal of a claim or a request for pre-authorization, as there has been greater examination of the prior authorization procedures within the program. A significant number of those surveyed opted for Medicare Advantage over Medigap due to worries about its cost-effectiveness. The Medicare Advantage sector is increasingly attracting insurance companies, with forecasts indicating that its membership will eclipse that of traditional Medicare in the foreseeable future.
For a medical professional to administer a particular treatment, obtaining a prior authorization from Medicare is necessary. The rationale behind prior authorization is fiscal prudence rather than the facilitation of treatment. Pre-authorization signifies that Medicare will only provide coverage if the medical service has been sanctioned in advance.
When you contest a determination regarding coverage or payment made by Medicare or your Medicare plan, you engage in an appeal process. For instance, one might lodge an appeal if Medicare or your plan rebuffs:
■ An entreaty for a medical service, supply, merchandise, or prescription medication that you believe you are entitled to receive
■ An entreaty for the cost of a medical service, supply, merchandise, or prescription medication you have acquired
■ An entreaty to modify the amount due for a medical service, supply, merchandise, or prescription medication
You are also in your right to appeal if Medicare or your plan ceases to provide or finance completely or partially a medical service, supply, merchandise, or prescription medication you deem necessary.
Contained within this booklet is the procedure for filing an appeal regardless of the manner in which you receive your Medicare benefits. For additional details, please visit Medicare.gov/appeals, or place a call to 1-800-MEDICARE (1-800-633-4227). For TTY users, the contact number is 1-877-486-2048.
