Mrs. Duarte is enrolled in Original Medicare Parts A

Mrs. Duarte is enrolled in Original Medicare Parts A and B. She has recently reviewed her Medicare Summary Notice (MSN) and disagrees with a determination that partially denied one of her claims for services.

What advice would you give her?

a. Mrs. Duarte should file an appeal of this initial determination within 90 days of the date she received the MSN in the mail. If she still disagrees with Medicare Administrative Contractor’s (MAC’s) further decision she should request a reconsideration by a qualified independent party within 10 days.

b. Mrs. Duarte should file an appeal of this initial determination within 120 days of the date she received the MSN in the mail.

c. Mrs. Duarte should request a reconsideration of the decision by a qualified independent party within 60 days of the date she received the MSN in the mail.

d. Mrs. Duarte has no right to appeal this determination since her claim has been partially paid.

The correct advice for Mrs. Duarte in this situation would be:

b. Mrs. Duarte should file an appeal of this initial determination within 120 days of the date she received the MSN in the mail.

Here’s why this is the correct answer:

1. Mrs. Duarte has the right to appeal: Even though her claim was partially paid, she still has the right to appeal the partial denial. Option (d) is incorrect because beneficiaries have appeal rights for both fully and partially denied claims.
2. The correct timeframe: For Original Medicare (Parts A and B), beneficiaries have 120 days from the date they receive the Medicare Summary Notice (MSN) to file an appeal of an initial determination. This makes option (b) the correct choice.
3. Why other options are incorrect:
   • Option (a) is incorrect because it states 90 days instead of 120 days, and it incorrectly combines two separate appeal levels into one step.
   • Option (c) is incorrect because it suggests requesting a reconsideration immediately, which is actually the second level of appeal, not the first step Mrs. Duarte should take.

The correct process for Mrs. Duarte would be:

1. File an appeal (also called a redetermination) within 120 days of receiving the MSN.
2. If she disagrees with the result of the redetermination, she can then request a reconsideration by a Qualified Independent Contractor (QIC), which would be the next level of appeal.

It’s important for Medicare beneficiaries to understand their appeal rights and the correct procedures to follow when they disagree with a coverage determination.

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