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The Politics of Health Care

Medicare Reviewing Denied Claims

Published February 4, 2014 9:37 AM by Michael LaMagna
As part of the settlement of the Jimmo v. Sebelius lawsuit, in which Medicare conceded that coverage is available for skilled services to maintain or not diminish an individual's condition, costing unnecessary cost and coverage denials, Medicare is reviewing previously denied claims. What this means is that if a person had a Medicare part A or part B claim denied, in part because it was determined that his/her condition plateaued or you show improvement, between Jan. 18, 2011 to Jan. 23, 2014, Medicare will review the claim, utilizing the new standard and may reverse the denial.

More specifically, a Medicare beneficiary may be eligible for the review of a past claim, if they:

1) received skilled nursing or rehabilitation services in a nursing home, home health care or outpatient therapy; and

2) received a partial or full denial of a claim based on the fact that they lacked improvement ; and

3) The denial was final and non-appealable on or after Jan. 18, 2011.

Appeals are always time sensitive. If a claim became final from Jan. 18, 2011 to Jan. 24, 2013, the deadline for the review is July 24, 2014; if a claim became final between Jan. 25, 2013 to Jan. 23, 2014, the deadline to file for the review is Jan. 23, 2015.

You can access the appeal form on the Center for Medicare Advocacy's website: www.medicareadvocacy.org.


This article is provided for informational purposes only. Nothing in this article shall be construed as legal advice or should be relied upon as such. Michael LaMagna is a Partner at Helwig, Henderson, Ryan, LaMagna & Spinola, LLP., practicing Elder Law/Probate/Disability/Wills, Trusts and Estates, Health Care Regulatory, Medicare Appeals, Social Security and General Legal practice in both New York and Connecticut. Email him at Mlamagna@hhrls.com, call him at 914-437-5955 or visit Attorney LaMagna's website at www.hhrls.com for more information.

posted by Michael LaMagna


This is incomplete and misleading. You can only request re-review if you paid for the care out of pocket or are on the hook for it from Medicaid.

Sven February 13, 2014 8:00 AM

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