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How to appeal a Medicare denial

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By Hook Law Center

If you were denied coverage or payment by Medicare, you have the option of filing an appeal. The denial must be from Medicare, your Medicare Prescription Drug Plan or your Medicare health plan. It is within your right to file an appeal if you were denied any of the following:

  • A health care service, prescription drug, item or supply which you think you are entitled to
    receive;
  • Payment for a health care service, prescription drug, item or supply that you already received;
  • A change in the amount you are required to pay for a healthcare service, prescription drug,
    item or supply.

You can also file an appeal if Medicare or your plan ceases to offer or pay for your health care service, prescription drug, item or supply. If you are enrolled in a Medicare Medical Savings Account (MSA) Plan, you can file an appeal if you believe that you have satisfied your deductible or you think that a service or item should be applied toward your deductible.

In the event that you decide to file an appeal, request any information that could be helpful to your case from your physician, health care provider or supplier. The appeals process consists of five levels. If you do not agree with the decision reached at any level, you can usually proceed to the next level.

The first step in filing an appeal is to review your Medical Summary Notice (MSN), which lists all of the services and supplies that were billed to Medicare during a time frame of three months. It also reveals the amount paid by Medicare, and the amount you may be required to pay the provider. In addition, the MSN shows whether Medicare has denied your medical claim.

You will receive an MSN by mail every three months. Should you decide to file an appeal, you must do so within 120 days of the day on which you received the MSN in question.

Here are the three ways in which you can file an appeal:

  1. Complete a “Redetermination Request Form” and mail it to the Medicare contractor.
  2. On the back of the MSN, there are instructions for you to follow. You are required to mail your
    request for redetermination to the firm that manages Medicare claims.
  3. Mail a written request to the firm that manages Medicare claims.

You can also consult an elder law attorney who can help you file an appeal of a claim or reimbursement that was denied.

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Posted on Monday, July 27th, 2015. Filed under Medicaid, Public Benefits.