Receiving a denial for a Medicare claim can be frustrating, but it is important to know that there is a structured process to appeal these decisions. Many individuals have successfully appealed their denials, making it a worthwhile endeavor for those affected.
If you disagree with a coverage or payment decision made by Medicare, the first step is to communicate with the healthcare provider, whether that be a doctor or a hospital. Often, billing code errors are the root cause of denials, and a simple resubmission may resolve the issue. If this does not rectify the problem, it is time to initiate the formal appeal process.
Understanding the Appeals Process for Original Medicare
For those enrolled in original Medicare, the first place to check is the quarterly Medicare Summary Notice (MSN). This document outlines all the services, supplies, and equipment billed to Medicare, along with explanations for any denied claims. You can access your claims early by visiting MyMedicare.gov or calling Medicare at 800-633-4227.
There are five levels of appeals available for original Medicare claims. If necessary, you can initiate a “fast appeal” if receiving services from a hospital, skilled nursing facility, home health agency, outpatient rehabilitation facility, or hospice. This request is especially relevant when the service is nearing its end.
You have 120 days from the date of the MSN to request a “redetermination” by a Medicare contractor. Begin by circling the disputed items on the MSN, providing a written explanation of why you believe the denial should be overturned, and including supporting documents, such as a letter from your doctor or hospital. Send this to the address specified on the MSN.
Additionally, the Medicare Redetermination Form is available for download at CMS.gov or by calling 800-633-4227 to request a physical copy. Typically, the contractor will make a decision within 60 days after receiving your appeal. If the request is denied, you can pursue a “reconsideration” with a different claims reviewer, providing further evidence to support your case.
A denial at this level concludes the matter unless the disputed charges exceed $190 in 2025. In that case, a hearing can be requested with an administrative law judge, usually conducted via videoconference or teleconference. If necessary, the appeal can continue to the Medicare Appeals Council, and for claims of at least $1,900 in 2025, the final level is judicial review in U.S. District Court.
Appealing Denials under Medicare Advantage and Part D
For individuals enrolled in a Medicare Advantage plan or Part D prescription drug plan, the appeals process differs slightly. In these cases, you have only 65 days to initiate an appeal, and you must address the appeal directly to the private insurance plan rather than Medicare.
If a denial jeopardizes your health, you can request an expedited appeal. For Part D insurers, a response must be provided within 24 hours, while Medicare Advantage plans must respond within 72 hours. The appeals process for these plans also consists of five levels, similar to original Medicare, allowing you to escalate your appeal if necessary.
To review the detailed procedures for appealing Medicare decisions, visit Medicare.gov/claims-appeals and click on “File an appeal.” It is crucial to keep photocopies and records of all communications with Medicare regarding your denial.
If you require assistance with the appeal process, you have the option to appoint a representative, such as a family member, friend, advocate, or attorney. Additionally, the State Health Insurance Assistance Program (SHIP) offers counselors who can assist with filing appeals at no cost. To locate your local SHIP, visit ShipHelp.org or call 877-839-2675.
Navigating the appeals process can seem daunting, but understanding the steps involved can significantly increase your chances of a successful outcome.
