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Medicare Advantage: Claims: Appeals

A Preferred Method Of Making An Appeal

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Consider making an appeal by calling from your doctor's office. You may get a "yes." At the least, you'll get a better understanding of why the Plan is saying "no." Immediately follow up the call with a letter.

A suggested scenario:

  • Work closely with your doctor before the call. Get your arguments in order.
  • Have the doctor available to get on the call to give his or her medical arguments directly. (You'll also get an opportunity to how strongly the doctor advocates for you).
  • Use the words "expedited appeal" when you call. For instance: "I'm calling to request an expedited appeal on your refusal to cover the MRI proposed by my doctor, Dr. Welby. I believe it should be covered because we still have not found what is causing my abdominal pains and cramps and an MRI seems to be the last diagnostic procedure. We need to rule out any type of cancer. As I understand it, an MRI is the only sure way to do it. May I put my doctor, Dr. Welby on the phone to explain it from a medical professional point of view?"
  • Keep a record of date, time, phone number(s), fax number(s), name(s) of people talked with, what was said, and what the next steps are.

After the initial phone call, fax written statements by yourself and your doctor via fax. This puts your arguments in writing and assures that your arguments will be passed on without change or editing. (It may help hone your and your doctor's arguments if you write the letter before the phone call. You can make last minute changes based on the phone call before faxing.) Call the Medicare Advantage Plan shortly after faxing the appeal letter to make sure it was received.

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