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A How-To:
Coverage Appeals

Almost all health insurers have a specific process to appeal an unfavorable coverage decision. Bristol-Myers Squibb (BMS) Access Support can assist in navigating the appeals process. However, the preparation and submission of documents to support the appeal is the responsibility of the patient and/or healthcare provider.

Bristol-Myers Squibb and its agents make no guarantee regarding the outcome of appeals assistance.

When you’re filing an appeal, keep in mind:
  • Coverage decisions may be made by an insurer before the treatment is rendered or after a claim is filed. Coverage decisions that are made before a treatment regimen is initiated are often referred to as “prior authorization” or “coverage determinations.”1
  • Medicare Part B and many other health insurers will not make a coverage decision regarding individual patients before a claim is filed. Coverage is considered only at the time a claim is presented for payment.2
  • The billing provider can usually appeal an insurer's decision to deny coverage for a claim.3 Appeals are almost always subject to timeliness requirements. The window of time allowed for a provider to appeal an unfavorable coverage decision usually begins on the date a claim was adjudicated (processed) by the insurer.2
  • If the health insurer approves an appeal, you will be notified and the claim will be reconsidered.
  • If the health insurer denies the appeal, contact BMS Access Support for further assistance at 1-800-861-0048.

Each plan has its own process and timeline for appeals. The appeals process for Medicare Part B contractors is determined by the Centers for Medicare and Medicaid Services (CMS) and is outlined below.

Medicare Appeals: Parts B and D

 

Medicare has a formal appeals process that is relatively easy to initiate but must be managed carefully to ensure that the appeal is properly prepared and that timely filing deadlines are not missed. Many non-Medicare health insurers follow similar procedures.

There are currently five levels of appeal in the Medicare Part B and Part D programs2:

REDETERMINATION
RECONSIDERATION
ADMINISTRATIVE LAW JUDGE HEARING
MEDICARE APPEALS COUNCIL
JUDICIAL REVIEW IN FEDERAL COURT

Each level of appeal must be completed before the patient is eligible to advance to the next level of appeal. In addition, there are time and dollar thresholds that must be met.

For more detailed information about the Medicare appeals process, including coverage determination, common exceptions and important filing deadlines.

References:
1. American Academy of Actuaries. Health Insurance Coverage and Reimbursement Decisions: Implications for Increased Comparative Effectiveness Research: 2008.
2. Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual. http://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/Downloads/clm104c29.pdf. Accessed January 4, 2016.
3. Healthcare.gov_appeals. How do I appeal a health plan decision? https://www.healthcare.gov/how-do-i-appeal-a-health-insurance-companys-decision/. Accessed January 7, 2016.

The accurate completion of reimbursement- or coverage-related documentation is the responsibility of the healthcare provider and patient. Bristol-Myers Squibb and its agents make no guarantee regarding reimbursement for any service or item.

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