What to Do When Medicare Denies a Claim
How do I go about a filing an appeal with Medicare when they will not pay for something that they covered in the past?
If you disagree with a coverage or payment decision made by Medicare, you can appeal. Approximately half of all Medicare appeals are successful, so it is definitely worth your time.
Before appealing, talk with your doctor, hospital and Medicare to see if you can spot the problem and resubmit the claim. Some denials are caused by simple billing code errors by the doctor's office or hospital. If that does not fix the problem, here is how you appeal.
If you have original Medicare, start with your quarterly Medicare Summary Notice (MSN). This statement will list all the services, supplies and equipment billed to Medicare for your medical treatment and will tell you why a claim was denied. You can also check your Medicare claims early online at MyMedicare.gov or by calling Medicare at 800-633-4227.
There are five levels of appeals for original Medicare, although you can initiate a fast-track consideration for ongoing care, such as rehabilitation. Most people have to go through several levels to get a denial overturned.
You have 120 days after receiving the MSN to request a redetermination by a Medicare contractor, who will review the claim. Make a copy of your MSN, then circle the items you are disputing on the MSN. Provide an explanation of why you believe the denial should be reversed and include any supporting documents like a letter from the doctor or hospital explaining why the charge should be covered. Then send it to the address on the form.
You can also use the Medicare Redetermination Form. See CMS.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS20027.pdf to download it or call 800-633-4227 to request a copy by mail.
The contractor will usually decide within 60 days after receiving your request. If your request is denied, you can request reconsideration from a different claims reviewer and submit additional evidence.
A denial at this level ends the matter, unless the charges in dispute meet a minimum threshold (at least $160 in 2019). In that case, you can request a hearing with an administrative law judge. The hearing is usually held by videoconference or teleconference.
If you have to go to the next level, you can appeal to the Medicare Appeals Council. Then, for claims of at least $1,630 in 2019, the final level of appeal is judicial review in U.S. District Court.
If you are enrolled in a Medicare Advantage health plan or Part D prescription drug plan the appeals process is slightly different. With these plans you have only 60 days to initiate an appeal. In both cases, you must start by appealing directly to the private insurance plan, rather than to Medicare.
If you think that your plan's refusal is jeopardizing your health, you can ask for a "fast decision," where a Part D insurer must respond within 24 hours, and Medicare Advantage health plan must provide an answer within 72 hours.
If you disagree with your plan's decision, you can file an appeal, which like original Medicare, has five levels. If you disagree with a decision made at any level, you can appeal to the next level.
For more information, along with step-by-step procedures on how to make an appeal, visit Medicare.gov and click on the "Claims & Appeals" tab at the top of the page.
If you need some help, contact your State Health Insurance Assistance Program (SHIP), which has counselors that can help you understand the billing process and even file your appeal for you for free. To locate your local SHIP, visit ShiptaCenter.org or call 877-839-2675. The Medicare Rights Center also offers free phone counseling at 800-333-4114.
Savvy Living is written by Jim Miller, a regular contributor to the NBC Today Show and author of "The Savvy Living" book. Any links in this article are offered as a service and there is no endorsement of any product. These articles are offered as a helpful and informative service to our friends and may not always reflect this organization's official position on some topics. Jim invites you to send your senior questions to: Savvy Living, P.O. Box 5443, Norman, OK 73070.
If you disagree with a coverage or payment decision made by Medicare, you can appeal. Approximately half of all Medicare appeals are successful, so it is definitely worth your time.
Before appealing, talk with your doctor, hospital and Medicare to see if you can spot the problem and resubmit the claim. Some denials are caused by simple billing code errors by the doctor's office or hospital. If that does not fix the problem, here is how you appeal.
Original Medicare Appeals
If you have original Medicare, start with your quarterly Medicare Summary Notice (MSN). This statement will list all the services, supplies and equipment billed to Medicare for your medical treatment and will tell you why a claim was denied. You can also check your Medicare claims early online at MyMedicare.gov or by calling Medicare at 800-633-4227.
There are five levels of appeals for original Medicare, although you can initiate a fast-track consideration for ongoing care, such as rehabilitation. Most people have to go through several levels to get a denial overturned.
You have 120 days after receiving the MSN to request a redetermination by a Medicare contractor, who will review the claim. Make a copy of your MSN, then circle the items you are disputing on the MSN. Provide an explanation of why you believe the denial should be reversed and include any supporting documents like a letter from the doctor or hospital explaining why the charge should be covered. Then send it to the address on the form.
You can also use the Medicare Redetermination Form. See CMS.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS20027.pdf to download it or call 800-633-4227 to request a copy by mail.
The contractor will usually decide within 60 days after receiving your request. If your request is denied, you can request reconsideration from a different claims reviewer and submit additional evidence.
A denial at this level ends the matter, unless the charges in dispute meet a minimum threshold (at least $160 in 2019). In that case, you can request a hearing with an administrative law judge. The hearing is usually held by videoconference or teleconference.
If you have to go to the next level, you can appeal to the Medicare Appeals Council. Then, for claims of at least $1,630 in 2019, the final level of appeal is judicial review in U.S. District Court.
Advantage and Part D Appeals
If you are enrolled in a Medicare Advantage health plan or Part D prescription drug plan the appeals process is slightly different. With these plans you have only 60 days to initiate an appeal. In both cases, you must start by appealing directly to the private insurance plan, rather than to Medicare.
If you think that your plan's refusal is jeopardizing your health, you can ask for a "fast decision," where a Part D insurer must respond within 24 hours, and Medicare Advantage health plan must provide an answer within 72 hours.
If you disagree with your plan's decision, you can file an appeal, which like original Medicare, has five levels. If you disagree with a decision made at any level, you can appeal to the next level.
For more information, along with step-by-step procedures on how to make an appeal, visit Medicare.gov and click on the "Claims & Appeals" tab at the top of the page.
Get Help
If you need some help, contact your State Health Insurance Assistance Program (SHIP), which has counselors that can help you understand the billing process and even file your appeal for you for free. To locate your local SHIP, visit ShiptaCenter.org or call 877-839-2675. The Medicare Rights Center also offers free phone counseling at 800-333-4114.
Savvy Living is written by Jim Miller, a regular contributor to the NBC Today Show and author of "The Savvy Living" book. Any links in this article are offered as a service and there is no endorsement of any product. These articles are offered as a helpful and informative service to our friends and may not always reflect this organization's official position on some topics. Jim invites you to send your senior questions to: Savvy Living, P.O. Box 5443, Norman, OK 73070.
Published December 13, 2019
