What if Medicare denies coverage?

If Medicare denies coverage of medical items, a medical service, or medical procedure, you may be able to appeal Medicare’s decision. If that is the case, you need to begin by reviewing your Medicare Summary Notice (MSN), which comes every three months either electronically or in the mail. The MSN, though not a bill, will notify you of all the services and supplies billed to Medicare. It will also tell you what Medicare paid, and the maximum amount you may need to pay your provider. On the last page, it even contains information on your right to appeal!

Before making an appeal, it’s a good idea to ensure you don’t have other insurance that will cover what Medicare didn’t. Also, if you find an item or service was denied, you should check with your health provider to see if they submitted the right information. In some cases, resubmitting your information is all you need to do to get Medicare to cover the services you need. However, make sure you complete these steps promptly. If you’re going to begin appealing a coverage determination from Medicare, you must do so within 120 days of getting your MSN or earlier, depending on your plan.

Making an appeal

Once you’ve completed these steps, you may find you still need to make an appeal. First, you should obtain any information you can from your doctor or health provider to help your case. Then you can either file an appeal yourself, or appoint a representative to act on your behalf. The easiest way to appoint a representative is to fill out and submit an “Appointment of Representative” form. You can also appoint a representative while sending in your first appeal. For more information on appointing Medicare representatives, visit our article here.

Now, the preliminary steps for filing an appeal differ slightly depending on the type of Medicare plan you have. There are:

  • Original Medicare appeals
  • Medicare health plan appeals (Medicare Advantage appeals)
  • Medicare Part D drug coverage appeals
  • Special Needs Plan (SNP) appeals

A good rule of thumb should you appeal is to contact your plan directly for details about your appealing rights. Your plan’s contact information can be found on your plan membership card. Or, you can search for contact information on Medicare.gov under “Personalized Search.”

All Medicare coverage appeals generally follow the same pattern. The five levels of the appeals process are as follows:

  1. Redetermination by the company that handles claims for Medicare
  2. Reconsideration from a Qualified Independent Contractor (QIC)
  3. Hearing before an Administrative Law Judge
  4. Review by the Medicare Appeals Council
  5. Judicial review by a federal district court.

Usually, if you don’t agree with the decision made at one of the levels, you can move to the next. However, this can be a time consuming and even expensive process. Throughout your appeal, you should keep a copy of everything you send to Medicare for future reference and in case you need it later in the appeals process.

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