If Your Medicare Part C (Medicare Advantage) Claim Is Denied
I have been a health insurance broker for over a decade and every day I read more and more "horror" stories that are posted on the Internet regarding health insurance companies not paying claims, refusing to cover specific illnesses and physicians not getting reimbursed for medical services. Medicare's annual open enrollment period starts on Monday, and beneficiaries can join Medicare Advantage plans, switch plans or return to original Medicare. Enrollment in CDPHP Medicare Advantage depends on contract renewal. There is also a complaint process if you are not satisfied with the quality of services that you received from United Behavioral Health or your behavioral health practitioner.
We must decide on a fast appeal no later than 72 hours after we get your appeal, but will make it sooner if your health requires us to. If we do not give you our decision within 72 hours, your request will automatically go to the second level of appeal, where an independent organization will review your case.
The appeal process is somewhat different depending on the denied item or service and whether you're filing an appeal with Original Medicare or with a Medicare Advantage plan or Prescription Drug Plan. If our answer is yes to part or all of your request, we will authorize or provide the coverage we have agreed to provide within 30 days after we receive the appeal.
If a Medicare Advantage plan gave you prior approval for a medical service, it can't deny you coverage later due to lack of medical necessity. The OIG notes that capitated payments used in the Medicare Advantage program could incentivize insurers to limit care in order to increase profits.
If that happens, and you feel there has been an error, you can file a Medicare appeal. Concluding that How to Appeal Medicare Advantage Denial you or your loved one's healthcare needs could effectively be managed at a lower level of care, such as a skilled nursing facility. Beneficiaries and providers rarely used the appeals process.
Aetna Medicare is a PDP, HMO, PPO plan with a Medicare contract. Medicare Advantage holds the promise of additional coverage for beneficiaries in a cost-controlled payment system achieved through collaboration with private insurers. A recent investigation by the U.S. Office of Inspector General found between 2014 and 2016, Medicare Advantage organizations overturned 75 percent of their preauthorization and payment denials upon appeal.