Medicare sometimes will decide that a particular treatment is not covered and the beneficiary’s claim will be denied. Many of these decisions are highly subjective and involve determining for example, what is “medically and reasonably necessary” or what constitutes “custodial care.”

Having a claim denied can be devastating to many individuals, especially if it was for a high dollar event. If this ever happens to you, it is important to know there are reconsideration and appeal procedures within the Medicare program.

While the Federal Government determines the rules surrounding Medicare, the day-to-day administration and operation of the Medicare program is handled by private insurance companies that have contracted with the government. For Medicare Part A, these insurers are called “intermediaries,” and for Medicare Part B they are referred to as “carriers.” In addition, the Government contracts with committees of quality improvement organizations (QIOs) to decide the appropriateness of care received by most Medicare beneficiaries who are patients in hospitals.

My Medicare Claim Was Denied; What Does This Mean?

If an intermediary carrier or quality improvement organization (QIO) decides Medicare should not pay for care you received, you will be notified of this when you receive your Medicare Summary Notice (MSN). The Medicare Rights Center recommends first, making sure that the coverage denial isn’t simply the result of a coding mistake.  You can start by asking your doctor’s office to confirm that the correct medical code was used.  If the denial is not the result of a coding error, you can appeal using Medicare’s review process.

Hopefully this resolves the issue, but in cases where the claim is still in a “denied” status after Medicare’s review process has been exhausted, the matter can be taken to court if the amount of money in dispute exceeds either $1,000 or $2,000, depending on the type of claim. Medicare beneficiaries can represent themselves during these appeal process, or they can be represented by a personal representative or Attorney. While the Medicare Rights Center estimates that only about 2% of Medicare beneficiaries actually appeal denials, 80% of those who do appeal Part A denials and 92% who appeal Part B denials win.

Even if Medicare ultimately rejects a disputed claim, a beneficiary may not necessarily have to pay for the care he or she received completely out-of-pocket. In situations where the recipient either did not know or could not have been expected to know that Medicare would not cover certain services, the recipient is granted a “waiver of liability”, and the health care provider is the actual party responsible for the economic loss.

How do I Appeal a Denied Medicare Claim?

Denials may occur for a variety of reasons. Below are just a few examples:

Denials for health care services, prescriptions, or supplies that you have already received (for example, the denial of a test ran during a visit to the doctor) occur when the doctor’s office submits a claim for reimbursement and Medicare determines it was not medically necessary and denies payment of the claim.

A denied request you or your doctor made for a health care service supply or prescription (for example, an order for a wheelchair) occurs when Medicare determines the item or service is not medically necessary.

A denied request related to Part D occurs when either you or your doctor request a change to a prescription drug (for example, your Medicare Part D drug plan rejects your doctor’s recommendation that you receive a discount on an expensive medication because the available lower-cost drugs are not effective for your condition) and the claim is denied.

Should this or any other situation result in a claims denial, you have the right to appeal. If you have your coverage through a Medicare Health Plan, see your plan materials or contact your plan for details about your appeal rights. Generally, you can find your plan’s contact information on your plan membership card. Make sure you ask your doctor, health care provider, or supplier for any information that may help your case.

The appeals process has five levels. If you disagree with the decision made at any level in the process, you can typically go to the next level. You will be provided with instructions during each step of the process.

For individuals with Original Medicare only wanting to file an appeal, you should start by looking at your Medicare Summary Notice (MSN) which is sent to you quarterly. You can also track your claims at any time on the MyMedicare.com website. Your MSN will show you everything that has been billed to Medicare over the last three months including what Medicare paid and what you may owe the provider. It will clearly show all denials (full and partial) here. Each MSN will have information regarding your appeal rights. You must file all appeals within 120 days from the date you receive your MSN.

There are two ways to file an appeal:

  1. Fill out a Redetermination Request Form (this can be found on the Medicare website) and send it to the Medicare Contractor at the address showing on your MSN.
  2. Follow the instructions for sending an appeal letter. Your letter must be sent to the company that handle claims for Medicare (this is listed in the “Appeals” section of your MSN) and should include the MSN with the disputed service(s) in dispute circled; an explanation regarding why you disagree; your Medicare claim number, full name, address, phone number; and any other information about your appeal that you would like to have considered. Make sure you sign your letter before sending.

To learn more, contact a Medicare Pathways sales agent by calling 866-466-9118.