Medicare

How to Appeal a Denied Medicare Claim

If your claim has been denied, follow these steps to help seek a redetermination.

If your claim is denied, first talk with the doctor (or hospital) and Medicare to see if you can identify the problem and get the claim resubmitted. “When Medicare rejects a bill, it’s often because it wasn’t billed properly,” says Murphy, of the Center for Medicare Advocacy. “Call the doctor’s office and ask why it was rejected.” The office may just need to coordinate Medicare with your medigap policy or fix a coding mistake.

If that doesn’t work, look on the back of the Medicare summary notice to find out how and when to appeal the denial. Traditional Medicare has several levels of appeal, each with a time line—and those time lines are rigid, says Sikora.

You have 120 days after receiving the Medicare summary notice to request a “redetermination” by a Medicare claims reviewer. Circle the item you’re disputing on the summary notice, then send any supporting information, such a letter from the doctor explaining why the charge should be covered. The claims reviewer will usually make the decision within 60 days of receiving your request.

If that appeal is denied, you have 180 days in which to request reconsideration from a different claims reviewer and submit additional evidence. Reconsideration is usually completed within 60 days. Failing a decision in your favor, for a charge of $150 or more, you have 60 days to request a hearing with an administrative law judge. For amounts of $1,460 or more, the final level of appeal is judicial review in U.S. District Court.

At each level, focus your appeal on the reason the claim was denied. To strengthen your case, keep records of your interactions with Medicare and the doctor or hospital involved. “You need to document every phone call or conversation—the name, date, time, what you are talking about,” says Diane Omdahl, president of 65 Incorporated, which helps people navigate Medicare. She took an appeal for her father’s skilled nursing care up to an administrative law judge and won.

You have 60 days to initiate an appeal involving a Medicare Advantage or Part D prescription-drug plan. In both cases, you must start by appealing to the private insurance plan rather than to Medicare. Follow the plan’s instructions on its explanation of benefits. Part D has a 72-hour fast-track appeal process if your health would be jeopardized by waiting for the prescription. Otherwise, the plan must make its decision within seven days.

For more information about each type of appeal, see Medicare.gov's How Do I File an Appeal? and Claims & Appeals sections. Your local State Health Insurance Assistance Program can help (go to www.shiptacenter.org, or call 800-633-4227 for contacts). Or call the help line at the Medicare Rights Center at 800-333-4114.

See Our Slide Show: 11 Common Medicare Mistakes

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