Appealing a Medicare denial
July 1, 2021 | View PDF
Every Medicare beneficiary has the right to appeal a denial of coverage for services or items made by Medicare. However, there are some things you should know. First, you need to understand why Medicare denied coverage in the first place. Then you need to build your case for the appeal and begin the process. You need to understand that there are multiple levels of appeals you can go through if your first decision is denied and each of these has their own timeline associated.
Why was your item or service denied coverage by Medicare? Make sure you read and understand all letters and notices that have been provided to you by Medicare and any other insurance coverage you may have. If you are not provided with the reason why you were denied coverage or you don’t understand the reasoning, call 1-800-Medicare (1-800-633-4227). They will be able to provide the reasoning for the denial, which is vital for building a strong case for your appeal.
You should be reading and reviewing your Medicare Summary Notice (MSN) as it arrives about every three months. This is the explanation of what benefits you received over the previous three months, what Medicare paid for these services, what you owe, and if a service was denied. If a service you received was denied coverage and you think it should have been covered, call your doctor and ensure that it was not a billing error.
You begin the appeals process by following the instructions on the last page of your Medicare Summary Notice. You will fill out the information requested on the Medicare Summary Notice and mail it to your Medicare Administrative Contractor (MAC) whose address is listed on your Medicare Summary Notice. You need to do this within 120 days of the date on the Medicare Summary Notice. You can strengthen your appeal by adding a letter of support from your provider if they also think Medicare should have covered the item or service provided. The Medicare Administrative Coordinator should have a decision on the appeal back to you within 60 days. If your appeal is denied, you can move on to the next level by following the instructions on the Medicare Administrative Contractor denial notice.
There are three additional levels of appeal if the Medicare Administrator Contractor denies the initial appeal. Each of these three levels have their own timeframes for completion and can increase in complexity. If you need help navigating the appeals process or want help initiating an appeal, call the Medicare Information Office and we can provide you with direction for your specific situation.
Colton T. Percy is a Certified Medicare Counselor and the Volunteer Coordinator for the Alaska Medicare Information Office. If you have questions about Medicare or are interested in volunteering and helping your fellow Alaskans navigate Medicare, please call 1-800-478-6065.