Medicare Advantage Appeal Outcomes And Audit Findings Raise Concerns About Service And Payment Denials Report

Almost 37% of all Medicare beneficiaries will be enrolled in Medicare Advantage plans in 2019, according to CMS projections. Pre-service appeals will be decided in 30 days and post-service appeals 60 days. But it added that it already uses several tools to oversee the Advantage program and ensure that enrollees have adequate access to healthcare services, including regular audits and enforcement actions.

On September 27, CMS published Medicare Claims Processing Transmittal 4141 , which rescinds and replaces Transmittal 4127, dated September 5, 2018, to revise business requirement 10871.6.1. The original transmittal was issued to provide the quarterly update to payment and edits in the Common Working File and Fiscal Intermediary Shared System to include and update new or existing influenza virus vaccine codes.

A grievance may be filed in writing or by contacting UnitedHealthcare® Customer Service at the telephone number (or the TTY number for the hearing impaired) listed in the Summary of Benefits or Chapter Two of the How to Appeal Medicare Advantage Denial Evidence of Coverage, 8 a.m.-8 p.m. local time, 7 days a week.

In some cases, the ratio of denials to appeals was drastic. Call 1-800-MEDICARE to request the telephone number of your State Health Insurance Assistance Program. Make sure to file your appeal within 60 days of the date on the notice. We collected data on denials, appeals, and appeal outcomes for 2014-16 at each level of the Medicare Advantage appeals process.

Your Level 1 appeal will be automatically forwarded to the Level 2 appeal process in two situations: first, if your Medicare Advantage Plan fails to give you a decision within the response deadlines noted above; or second, if the Medicare Advantage Plan does not decide in your favor during the Level 1 review.

If you are not happy with the decision made, you can request an appeal. If you are a Keystone 65 HMO member, you can file a standard or expedited medical appeal by using one of the methods below. OIG found that the range of claims appeals in MAOs was significant.