Medicare Coverage
If my Medicare coverage stops, can I appeal?
Yes. The Notice of Non Coverage explains how to appeal the Review Committee's decision. This appeal, referred to as a Review, will be conducted by the Massachusetts Peer Review Organization (MassPRO). MassPRO is funded by the federal government and is staffed by health professionals who independently review the care Medicare beneficiaries receive.
To begin the appeal process
Telephone the MassPRO by noon of the next working day after receiving the notice, so that you will not be financially liable for any covered hospital charges until the MassPRO informs you in writing of its Review decisions. MassPRO usually acts within a day or so. Follow up your telephone call with a letter. Keep a copy of your letter.
You can request a MassPRO Review later than noon of the next working day after receiving the NNC, but you will not be protected from financial liability.
Do I have further appeal rights if my benefits are denied after my first appeal?
Yes. If you are not satisfied with the MassPRO Review, you may appeal again, although you may be financially responsible for any additional stay beginning the day the Review is issued. This next stage of the appeals process, a Reconsideration, is explained in the Review notice from the MassPRO. You may request a Reconsideration up to sixty days after the receipt of the MassPRO's Review.
The MassPRO usually conducts a Reconsideration immediately. However, you are not protected from financial liability while awaiting the Reconsideration results.
When should I request a hearing?
If you are liable for more than $200.00, you may request a hearing before an Administrative Law Judge (ALJ) of the Social Security Administration. You must request this hearing within sixty days of receiving the Reconsideration. The Reconsideration will explain your right to request a hearing.
When should I have legal representation?
It is very helpful to have legal representation at a hearing before an Administrative Law Judge because Medicare coverage laws are very specific and sometimes confusing. A legal representative will review the circumstances regarding your hospitalization and your medical records to be sure that you received a level of care covered by Medicare.
Do I have further appeal rights beyond the hearing?
Yes. If you disagree with the ALJ decision, you have sixty days to request a review by an Appeals Council. The Appeals Council, located in Virginia, will decide to either affirm the Administrative Law Judge's decision, reverse the decision, or send the case back to an ALJ to be heard again. After this stage, you may appeal to the United States District Court if the amount in question is $2,000.00 or more.