How to appeal a Medicare coverage denial

Dear Savvy Senior, What steps do I need to take to appeal a denied Medicare claim?

— Frustrated Retiree

Dear Frustrated, If you disagree with a coverage or payment decision made by Medicare, you can appeal, and you’ll be happy to know that many appeals are successful, so it’s definitely worth your time.

But before going that route, talk with the doctor, hospital and Medicare to see if you can spot the problem and resubmit the claim. Many denials are caused by simple billing code errors by the doctor’s office or hospital. If, however, that doesn’t fix the problem, here’s how you appeal.

Original Medicare appeals

If you have original Medicare, start with your quarterly Medicare Summary Notice (MSN). This statement will list all the services, supplies and equipment billed to Medicare for your medical treatment and will tell you why a claim was denied. You can also check your Medicare claims early online at MyMedicare.gov, or by calling Medicare at 800-633-4227.

There are five levels of appeals for original Medicare, although you can initiate a "fast appeal" if you’re getting services from a hospital, skilled nursing facility, home health agency, outpatient rehabilitation facility or hospice, and the service is ending.

You have 120 days after receiving the MSN to request a "redetermination" by a Medicare contractor, who reviews the claim. Circle the items you’re disputing on the MSN, provide a written explanation of why you believe the denial should be reversed, and include any supporting documents like a letter from the doctor or hospital explaining why the charge should be covered. Then send it to the address on the form.

You can also use the Medicare Redetermination Form. See CMS.gov/Medicare/CMSForms/ CMSForms/ downloads/CMS20027.pdf to download it or call 800-633-4227 to request a copy by mail.

The contractor will usually decide within 60 days after receiving your request. If your request is denied, you can request for "reconsideration" from a different claims reviewer and submit additional evidence.

A denial at this level ends the matter, unless the charges in dispute are at least $190 in 2025. In that case, you can request a hearing with an administrative law judge. The hearing is usually held by videoconference or teleconference.

If you have to go to the next level, you can appeal to the Medicare Appeals Council. Then, for claims of at least $1,900 in 2025, the final level of appeals is judicial review in U.S. District Court.

Advantage and Part D appeals

If you’re enrolled in a Medicare Advantage health plan or Part D prescription drug plan the appeals process is slightly different. With these plans you have only 65 days to initiate an appeal. And in both cases, you must start by appealing directly to the private insurance plan, rather than to Medicare.

If you think that your plan’s refusal is jeopardizing your health, you can ask for an expedited (fast) request, where a Part D insurer must respond within 24 hours, and Medicare Advantage health plan must provide an answer within 72 hours.

If you disagree with your plan’s decision, you can file an appeal, which like original Medicare, has five levels. If you disagree with a decision made at any level, you can appeal to the next level.

For more information, along with step-by-step procedures on how to appeal Medicare, go to Medicare.gov/claims-appeals and click on "File an appeal." Also make sure to keep photocopies and records of all communication with Medicare, whether written or oral, concerning your denial.

Need help?

If you need help filing an appeal, you can appoint a representative (a relative, friend, advocate, attorney or someone else you trust) to help you. Or contact your State Health Insurance Assistance Program (SHIP), which has counselors that can file your appeal for you for free. To locate your local SHIP, go to ShipHelp.org or call 877-839-2675.

Send your questions or comments to [email protected] or to Savvy Senior, P.O. Box 5443, Norman, OK 73070.

JIM

MILLER

Savvy Senior