Denied: How to Appeal a Medicare Claim Decision

By RetireMEDiQ

No one likes to find out that their Medicare claim has been denied. It can be a shock to you and your wallet! If you receive a notice that your Medicare claim has been denied, it is important to first contact your insurance company to determine why they denied the claim. Next, contact your doctor’s office and ask them to re-submit the claim to your insurance company with proper documentation, if necessary.

If your claim remains denied after you complete these steps and you would like to appeal the decision, refer to our tips below to help you navigate the appeals process.

When to Appeal a Medicare Denial

Thanks to the appeals system, you may challenge decisions by Medicare regarding what they will cover for health care services, supplies and prescriptions. In certain cases, you even have the right to an expedited appeal. Unfortunately, many people don’t pursue an appeal because they find the process to be so complicated. There are many rules, and there are only certain windows of time during which you can file an appeal.

Filing an appeal is appropriate when you feel that you were unreasonably denied:

  • Coverage for a service, supply or prescription you have already received, such as a test that a doctor ordered and completed during a previous visit.
  • Coverage for a request that your doctor deemed medically necessary, like a wheelchair.
  • A price-change request for a prescription medication. If your Medicare Part D plan does not cover an expensive medication that your doctor recommends for your health care, you may submit a request for the plan to cover the medication if no other lower-cost alternatives are available.

How to Appeal a Medicare Decision

The steps for filing an appeal depend on which part of Medicare (Part A, B, C or D) you are appealing. The time frame for the appeals process also varies based on the Medicare claim you are challenging. A list of the initial claims process for each type of Medicare coverage can be found here.

  • Appealing a Part A or Part B denial: Find the specific service or request that was denied on your Medicare Summary Notice (MSN). In writing, provide your decision to appeal the denial. If possible, gather supporting documentation from your doctor, insurance company, health equipment supplier, etc. Follow the instructions provided on your MSN on how to appeal a claim. Don’t forget to include your name and contact information—and save copies of everything for your own records!
  • Appealing a Part C denial: Part C plans, also known as Medicare Advantage plans, are provided by private insurance companies. Medicare requires each insurance company to have an appeals system in place in case you need to use it. The best course of action is to follow your insurance company’s specified appeals process.
  • Appealing a Part D denial: Much like Part C, your prescription drug insurer determines the appeals process for a Part D denial. For example, you may request coverage for a specific medication that is not on your plan’s formulary. In this case, you will need to provide a written statement from your doctor that explains why you should be granted an exception.

The initial steps outlined here are just the beginning of the appeals process. We recommend that you research exactly how to challenge your specific type of claim denial.

Know Where to Find Help

Our team of licensed Client Advisors is here to serve clients like you all year long. If you are having trouble navigating an appeal, call us at 1-877-222-1942 for assistance!

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