If you have Original Medicare, your doctors and other health care providers send bills for your care directly to Medicare. You will later receive a statement called a Medicare Summary Notice (MSN) from Medicare—one for Part A, and one for Part B—outlining all the services and/or supplies that were billed to Medicare. The MSN also highlights how much Medicare paid for the services and supplies, how much you still owe, and any denied claims.
Outlined below is the process of appealing a denied claim that appears on your MSN.
Types of Claim Denials
There are several circumstances under which Medicare might deny a claim:
- Denial of services, prescriptions, or medical supplies already received — For example, your doctor conducts an MRI and sends Medicare a reimbursement claim for the test. Medicare denies payment, stating that the test was not medically necessary.
- Denial of a requested service, prescription, or supply –– For example, Medicare denies your claim for a replacement wheelchair on the basis that your current wheelchair should have lasted longer.
- Denial of a request for a prescription drug at a lower rate –– For example, a low-cost drug proves ineffective for your condition, but Medicare denies a request by you and your doctor for a reduced price on a more expensive alternative drug.
Filing an Initial Appeal for a Part A or Part B Claim Denial
Step 1: Carefully review your MSN statement, circling the item(s) that you are appealing. Write an explanation outlining why you think Medicare’s decision is wrong on a separate sheet of paper, and attach it to the MSN.
Step 2: Include supporting documentation from your doctor, healthcare provider, or equipment provider whenever possible, which can only strengthen your case.
Step 3: Carefully review any instructions included on the MSN about how to file a claim, and file your appeal within 120 days of receiving your MSN notice.
Step 4: Make copies of everything you send for your records, and store them in an easily accessible place.
Step 5: Submit your appeal to the address listed at the bottom of your MSN notice.
What if My Appeal Is Denied?
The initial appeal described above is called a “redetermination.” If you’re not satisfied with Medicare’s decision after you file your redetermination, you can file a second request called a “reconsideration,” during which an independent review organization (called a qualified independent contractor or QIC) will assess your appeal.
If neither of these reviews meets with your satisfaction, the appeal can be further escalated before an administrative law judge (in which case you’d likely want to be represented by an attorney). If the outcome is still unfavorable, you can escalate your case to the Medicare Appeals Council for review. Ultimately, your appeal can be taken all the way to the federal court system. Most cases are handled at the redetermination and reconsideration levels, however.
Our next post will outline how to appeal a Medicare claim decision for a Medicare Advantage (Part C) plan and Part D prescription drug plan, both of which are administered through private insurance carriers.