How to handle a denied Medicare claim?

If Medicare denies a claim, you have the legal right to file an appeal or request a review of the decision.

1. Review the Notice and Reason for Denial

• Check your statement: Look at your Medicare Summary Notice (MSN) if you have Original Medicare, or your Explanation of Benefits (EOB) if you have a Medicare Advantage plan.
• Identify the cause: Locate the specific denied item or service and read the listed reason. It may be a simple clerical error, missing information, or a ruling that the service is "not medically necessary".
• Fix simple errors: If the denial is due to a minor mistake or missing data, contact your doctor or healthcare provider immediately to correct and resubmit the claim.

2. Understand the Appeals Process

If the claim cannot be resolved by resubmitting, you can launch a formal five-level appeal process. The exact steps depend on your coverage type:

• Original Medicare (Parts A and B):
  • Level 1 (Redetermination): Circle the denied item on a copy of your MSN, write down why you disagree, and mail it to the Medicare Administrative Contractor (MAC) listed on the notice within 120 days. The MAC typically decides within 60 days.
• Medicare Advantage (Part C) or Part D Prescription Plans:
  • Level 1: You must appeal directly to your private plan, not to Medicare. You generally have 60 to 65 days from the date of the notice to file.
• Higher Levels: If you are denied at the first level, you can continue to subsequent levels of review (such as reconsideration by an independent contractor, an administrative law judge hearing, and federal review) provided your claim meets minimum dollar thresholds.

3. Strengthen Your Appeal

• Get provider support: Ask your doctor for a formal letter of medical necessity and supporting medical records.
• Keep records: Save copies of all documents, letters, and notes from phone calls (including representative names and dates).

4. Get Free Help

• Contact SHIP: Get free, personalized counseling from your local State Health Insurance Assistance Program (SHIP).
• Call Medicare: Reach out directly via the Official Medicare Contact Page or call 1-800-MEDICARE (1-800-633-4227).

If Medicare denies a claim, you are generally responsible for paying the costs, but you have the right to appeal the decision.

Financial Responsibility

• Patient liability: If a claim is denied by Original Medicare or a Medicare Advantage plan, the healthcare provider may bill you for the service or item.
• Advance Beneficiary Notice (ABN): If your provider thought Medicare might deny the service and had you sign an ABN beforehand, you are legally responsible for the payment.
• Provider billing rules: If the denial is due to a simple clerical error or missing information, the provider should fix and resubmit the claim rather than forcing you to pay.

Taking Action

• Review the notice: Check your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) to see why Medicare denied the claim.
• File an appeal: You or your provider can ask for a review or appeal the decision within 120 days for Original Medicare (or 60 days for Medicare Advantage).
• Get help: Contact your local State Health Insurance Assistance Program (SHIP) for free personal counseling.

A common reason for Medicare to deny coverage is when a service or item is deemed not medically necessary for diagnosing or treating an illness or injury.

Top Reasons for Coverage and Claim Denials

• Lack of Medical Necessity: Medicare rules state that treatments must meet accepted standards of medical practice and fit your specific condition.
• Billing and Coding Errors: Typos, missing details, or incorrect/outdated billing codes submitted by a healthcare provider frequently cause rejections.
• Statutorily Excluded Services: Certain items like routine dental care, cosmetic surgery, and long-term custodial nursing care are never covered by Original Medicare.
• Missing Prior Authorization: Some Medicare Advantage plans or specialized services require approval before you receive care.
• Out-of-Network Providers: Visiting a doctor or facility that does not accept the specific plan's network terms can lead to a refusal to pay.

Common reasons for Medicare claim denials include billing errors, missing prior authorizations, and determinations that a service is not medically necessary.

Top Reasons for Denials

• Billing and Coding Errors: Typos, incorrect patient ID numbers, mismatched diagnosis and procedure codes, or missing details.
• Lack of Medical Necessity: Medicare decides the treatment or test does not meet its specific coverage criteria or local guidelines for a given condition.
• Missing Prior Authorization: The doctor fails to get approval from the Medicare Advantage plan or Part D drug plan before providing the service.
• Duplicate Claims: The same service or claim is submitted more than once before the first one is processed.
• Statutorily Excluded Services: The item or care is never covered by Medicare, such as cosmetic surgery, routine dental care, or custodial long-term care.
• Missed Deadlines: The provider files the claim past Medicare's strict 12-month timely filing limit from the date of service.
• Coordination of Benefits Issues: Missing information regarding a patient's primary insurance carrier when another payer should be billed first.

The first step in appealing a Medicare denial is requesting a redetermination from the organization that processed the claim.

How to Start Your Appeal

• Check your notice: Look at your Medicare Summary Notice (MSN) if you have Original Medicare, or your written denial notice / Explanation of Benefits (EOB) if you have a Medicare Advantage or Part D plan.
• Note the deadline: For Original Medicare, you generally have 120 days from the date on your MSN to file. For Medicare Advantage or Part D plans, you usually have 60 to 65 days from the date of the denial notice.
• Submit your request: File a request for redetermination in writing—using the Redetermination Request Form (CMS-20027) or a signed letter—and send it to the address listed on your denial notice. Include any helpful supporting medical records or doctor's notes.