Each month that you use your Medicare benefits, you should receive an Explanation of Benefits from your Medicare plan.
The Explanation of Benefits (EOB) is a monthly statement you receive from your Medicare Part D or Medicare Advantage plan. It describes your prescription drug claims and costs from the previous month.
What should you do when you receive the Explanation of Benefits?
It's important to note that the Explanation of Benefits is not a bill, although it likely includes information about how much you owe your provider. Your drug plan sends you the EOB every month so you can review your claims. Your main responsibility is to review the EOB for errors.
If a claim is denied, the Explanation of Benefits should explain why. There is no universal format for an EOB, so what this section is called varies according to the insurance company that provides your prescription drug plan. Look for a section with notes or comments, which may not be on the first page of your statement.
In the event you see an error on your EOB, call your plan provider. You should also do this if a claim was denied, or a portion of services were not covered. After talking to your plan, you may wish to file an appeal. We include information about filing an appeal below.
Do all Medicare beneficiaries receive an Explanation of Benefits?
You only receive an Explanation of Benefits if you have either a Medicare Advantage Prescription Drug plan (MA-PD) or Medicare Part D prescription drug plan.
The Explanation of Benefits does not apply to Original Medicare. Instead, if you have Medicare Part A and Part B, you'll receive a Medicare Summary Notice once every 3 months (see below).
How often will you receive the Explanation of Benefits?
Most plans send you an EOB every month. This is not a requirement, though, so check with your plan to be sure.
Is the Explanation of Benefits the same as the Medicare Summary Notice?
No, the Explanation of Benefits is not the same thing as the Medicare Summary Notice (MSN).
Private insurance companies send the EOB to their plan members. You only receive the MSN if you have Original Medicare. Similar to the Explanation of Benefits, the MSN details all of the covered services you received under Medicare Part A and Medicare Part B over the past 3 months. It also explains what Medicare paid and the amount you may owe your provider.
You don't have to wait for the MSN, by the way. You can access it at any time through your MyMedicare.gov account, although you usually have to wait 24 hours for Medicare to process the claim. Once you enter your account, just press the Blue Button to see your Original Medicare claim information.
How can you check the status of your Medicare Part D claims?
In addition to reviewing your monthly Explanation of Benefits, you can use the same Blue Button option on your MyMedicare.gov account. You may also contact your plan provider directly.
For information about your Medicare Advantage claims, you need to contact the insurance company that provides your plan.
Do you need to save your EOBs?
You don't have to save your Explanation of Benefits notifications, but it's always a good idea – particularly if you claim medical expenses on your income taxes. They may also come in handy if you have a claim dispute or billing issue later.
How to appeal a Medicare Part D denial of coverage
If your plan refuses to cover a prescription, your pharmacist should give you a written notice that describes your rights. Start the appeal process by calling your plan to determine why it refuses to cover your medication. (This is not part of the formal appeal process, as you still do not have written notice that the plan has denied coverage.)
Once you know why coverage was denied, you can talk to the provider who prescribed the medication. It may be possible to switch to a comparable drug that is covered by your plan. If this isn't an option, though, your healthcare provider can help you file a formal appeal.
The next step is an exception request, where you ask the plan to make an exception for this medication or to place it on a lower tier. Your doctor is not required to help you with this, but you should ask them to supply a letter of support. You should receive a plan decision within 72 hours. Or, if you request an expedited request, you'll have a decision within 24 hours. Typically, you must be able to demonstrate a health reason supporting your need for expediting your request.
Appeal Level 1
If your plan approves your exception request, no further steps are required. If not, you'll receive a Notice of Denial of Prescription Drug Coverage. You now have 60 days to file a formal appeal. Follow the instructions included with the notice. Your plan has 72 hours to respond.
Appeal Level 2
The drug will be covered if your plan approves your appeal. If not, though, you move to the next step, Independent Review Entity (IRE). Again, you have 60 days to file, starting with the date listed on the denial. You should have a response within 72 hours.
Appeal Level 3
If your appeal is denied AND the drug is worth at least $180 in 2023, the next level is to request a decision from the Office of Medicare Hearings and Appeals (OMHA). An Administrative Law Judge (ALJ) typically makes this decision.
Appeal Level 4
The fourth level of the Medicare appeals process is Review by a Medicare Appeals Council. If your level three appeal is denied, follow the instructions included in the notification from the ALJ.
Appeal Level 5
Your final option is review by a federal district court. But this is only available for claims of at least $1,760 in 2023. In both level four and level five, you may be able to combine claims to reach the minimum dollar amount.
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