Social Security Disability Insurance Advocate

The Arizona Supreme Court, in an interesting case involving a Medicare-related coverage dispute between a Medicare Advantage plan administrator, United Behavioral Health (UBH), and two inpatient psychiatric care providers, held that the Medicare administrative appeals process preempts the arbitration language contained in the UBH provider agreements. The importance of pushing back when Medicare says no was highlighted recently by settlement of a class action lawsuit that will force Medicare to start covering skilled nursing and therapy services in institutional or home care settings - not only when patients have a demonstrated medical potential to improve, but also when they need care to maintain their current health status.

MAOs are to use the capitated payments to pay for all the medically necessary care for the enrolled beneficiary as long as the services are within Medicare's benefits package. The exception is hospice care, which is covered directly under Medicare Part A instead of through the Medicare Advantage plan.

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 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.

The findings reveal concerns about service and payment denial among Medicare Advantage, which covers more than 20 million Medicare beneficiaries in 2018. In some cases, the ALJ may decide to forgo a hearing altogether and may decide the case on-the-record” when the evidence in the claim file supports a decision in your favor.

If you disagree with the information provided by a pharmacist, you can contact your drug plan to ask for a How to Appeal Medicare Advantage Denial coverage determination. The Medicare Advantage Organization that originally denied the claim reviews the decision, but must assign a reviewer who was not involved in the original determination.