This content originally appeared on diaTribe. Republished with permission.
By Kara Miecznikowski and Eliza Skoler
Learn how to appeal a Medicare claim rejection under traditional fee-for-service Medicare, a Medicare health plan, or Medicare prescription drug coverage
A health insurance claim is a bill for your healthcare services, medications, or medical equipment that you think should be covered by your insurance plan. If you have Medicare health insurance, your healthcare practitioner will usually submit claims directly to Medicare for payment. If Medicare decides to reject the claim, you can challenge the decision. This is called an appeal.
In the United States, people have the right to appeal a denied claim for up to six months after hearing about this decision. Appeals can often be successful – a 2018 report showed that 75% of Medicare Advantage denials were overturned in the appeals process – which means that challenging a denied claim could save you money. This article will explain how to appeal a Medicare claim rejection.
To learn more about the appeals process in the United States – especially if you have a different health insurance plan – read our article, “When Insurance Gets Turned Down: Appeals Explained.”
How do Medicare appeals work?
You can appeal a decision made by the national Medicare fee-for-service program (Parts A and B), your private Medicare health plan (Part C), or your Medicare Prescription Drug Plan (Part D). Learn more about the different types of Medicare here.
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Here are some common situations for appealing a claim rejection:
- If you have already received the service, medication, or medical supplies. Example: your doctor gives you lab tests during a visit, but then Medicare rejects the claim.
- If your doctor requested the service, medication, or medical supplies for you. Example: your doctor says you need an insulin pump and Medicare decides that is not medically necessary.
- If you and your doctor request a change in price for your medication, based on what treatments work for you. Example: generic drugs do not work for your condition, so your doctor asks for a discount on the more expensive drug.
The appeals process is different under Medicare Part A, B, C, or D. There are five levels to the appeals process. If you disagree with the appeal decision at level one, you can continue to appeal the decision again at every other level.
With each appeals processes, write your Medicare number on every document you submit for your appeal, and keep a copy of all the materials you send in.
- Your bill will be sent directly to Medicare.
- The appeal must be filed within 120 days of receiving the Medicare Summary Notice (MSN) that shows that your claim was denied.
- If you disagree with a Medicare coverage decision in the MSN, you can appeal the decision.
A Medicare Summary Notice (MSN) is a summary of the health care services you have received over the past three months, sent to you by mail. It shows what Medicare paid for each service and what you owe for the service, and it will show if Medicare fully or partially denied a medical claim. The MSN also contains your appeal rights and step-by-step directions on when and how to file an appeal for a claim rejection.
Did you sign an Advanced Beneficiary Notice of Noncoverage (ABN) before you received the treatment? An ABN is a notice that your healthcare provider will give you if they think the health services they are recommending might not be covered by Original Medicare. Your ABN will list the items that Medicare is not expected to pay for, as well as the estimated costs of those health services. The ABN can help you decide if you would still like to receive the treatment, and if you will pay for it if Medicare declines to cover the cost.
When you sign an ABN you can ask your healthcare provider to submit the claim to Medicare (before billing you), asking Medicare to cover the cost. If Medicare rejects the claim, you can appeal the decision. If your healthcare provider did not give you an ABN before treatment, you might not be responsible for paying for the health service. Learn more ABNs and appeals here.
There are three different ways to file an initial appeal under Original (Part A or B) Medicare:
- Fill out a “Redetermination Request Form” with information from your MSN; send the form to the address provided on your MSN
- Follow instructions on your MSN for filing an appeal without using the form:
- Circle the claim that you disagree with on your MSN
- On a separate piece of paper, explain why you disagree with the decision
- Write your name, address, phone number, and Medicare number on the MSN, and sign it
- If you have any other information that will support your case, include it; you can ask your doctor or other health care provider to help you
- Send all of the above materials to the address listed under “Appeals Information” on your MSN
- Or, send a written request to the company that processes Medicare claims. Include:
- Your name and Medicare number
- The item that you disagree with on the MSN
- An explanation of why you disagree with the decision
- Your signature
- Send all of the above to the address provided under “Appeals Information” on the MSN
You should receive a decision within 60 days of your request, unless you submit extra information after you first file the appeal (which may delay the decision).
For more information on the Original Medicare initial appeals process, see the Medicare webpage. If you disagree with the appeal decision at the first level, you have 180 days to file an appeal at the second level; information on the appeals process beyond level one can be found here.
- The initial appeal must be filed within 60 days of receiving the claim rejection.
- You must send a written request (unless your plan allows you to file a standard request by phone, fax, or email instead).
In your request, include:
- Your name, address, and Medicare number
- The item you disagree with, the date that you received the service, and an explanation of why you disagree with the decision
- Any other information that may support your case
You should receive a decision about your appeal within 60 days, unless Medicare needs more time to obtain information from your healthcare provider. If waiting for a decision will hurt your health, your appeal decision will be made within seven days.
If your appeal is rejected (fully or partially), your request will automatically be sent to level two of the appeals process. More information on the initial appeals process under Medicare Part C can be found here. For information on the process after level one, click here.
- Reasons to request an exception to your Part D drug plan:
- If your plan decides not to provide a medication you think should be covered.
- If cheaper versions of your medication don’t work for you, you can ask for a discount on the more expensive medication.
- If a drug you need is not on your plan’s drug list, you can ask for an exception.
- An exception request must be submitted first; if your exception request is denied, you have 60 days to appeal the prescription drug claim rejection.
- You must send a written request (unless your plan allows you to file it in another way).
An “Evidence of Coverage” document explains your rights with your Medicare prescription drug plan. You have the right to ask your plan to pay for a medication you think should be covered, and you have the right to request an appeal if you disagree with your plan’s decision to provide it.
Before appealing a claim rejection, you will request an exception:
- Fill out a Medicare Prescription Drug Coverage Determination request form through your insurance plan sponsor
- Ask the healthcare provider who prescribed your medication to write a letter explaining why you need this medication
- Send the documents to your Medicare health plan
You should hear back about your request within 72 hours. If your exception is denied, you can appeal the claim rejection. To submit a written appeals request, include:
- Your name, address, and Medicare number
- The drug you want your plan to cover
- An explanation of why you are appealing the coverage decision.
- Any other information that may support your case, including medical records
- Send the documents to your Medicare health plan
You should receive a decision within seven days. If waiting for a decision will hurt your health, your appeal decision will be made within 72 hours.
More information on the initial prescription drug appeals process can be found here. If your request is not met (fully or partially), you have 60 days to appeal the decision at the next level; learn about further appeals here.
How can I get help filing an appeal?
You can have someone else file an appeal for you. This can be a family member, friend, lawyer, doctor, or anyone else that has agreed to be your representative. For more information and the representative form, see the Medicare website page on how to appoint a representative. For prescription drug appeals, your doctor or prescriber can request an initial appeal for you; you do not need to first fill out a form.
For more help with appeals, especially appeals beyond level one, contact your State Health Insurance Assistance Program (SHIP). SHIP is a network of free counseling services that help people navigate Medicare; find the SHIP program in your state here.
This article is part of a series on access that was made possible by support from AstraZeneca. The diaTribe Foundation retains strict editorial independence for all content.