How to Appeal a Denied Medicare Claim: A Step-by-Step Guide for Seniors
Getting a Medicare claim rejection can be incredibly frustrating, especially when you’re relying on Medicare to cover expensive healthcare services.
Unfortunately, health insurance denials are not uncommon. In fact, the KFF Survey of Consumer Experiences with Health Insurance found that 18% of insured adults say they experienced denied claims in the past year.
If you’ve had a Medicare claim denied, you can use the appeal process to challenge the decision.
At Senior Insurance Agency, we help our clients navigate the ins and outs of the Medicare system, including the appeals process. Here’s a step-by-step guide to help you appeal a denied claim with ease.
What Is a Medicare Denial?
A Medicare denial occurs when Medicare refuses to pay for a health care service or item that a patient requests. According to research from Definitive Healthcare, Medicare denies an average of 6.8% of inpatient claims and 1.6% of outpatient claims.
There are several reasons why you might be denied coverage for a specific service or item. Here are some of the most common reasons for Medicare denied claims.
- The item or service requested is not a medical necessity.
- The Medicare beneficiary has reached or exceeded the health coverage limit specified in their plan.
- The healthcare provider uses the incorrect billing code when filing the claim.
Whatever your reason for denial may be, know that you have options. Let’s explore them together.
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What to Do if Medicare Denies a Claim
If Medicare initially denies your claim, don’t panic. Instead, follow these steps to appeal the claim and request coverage.
Step 1: Review the Denial Notice
Every four months, Original Medicare beneficiaries receive a Medicare summary notice (MSN) in the mail. This document details your Medicare transactions during that quarter, including any services that were denied. The last page of the MSN provides a form you can use to file an appeal in writing.
In most cases, an MSN won’t provide a reason why services were denied. If this is the case for you, you may need to contact Medicare directly to learn more. One of the easiest ways to do this is by using the live chat feature on mymedicare.gov.
Step 2: Gather Necessary Information
Once you’ve received your MSN and contacted Medicare to identify the reason your claim was denied, review the claim carefully for mistakes. It is possible that your services or healthcare needs were documented incorrectly.
If your denial is the result of a mistake, you will need to prove that your services were reported erroneously. If the denial was not a mistake, you will need to prove that the services were medically necessary or otherwise supposed to be covered under your current policy.
Collect as much evidence as possible about the medical services in question. This includes official medical records, communications with your doctor, related financial records, and any other relevant documentation.
Step 3: Contact Medicare or Your Insurance Provider
If you have not already contacted Medicare directly, now is the time to get in touch. You can do this via live chat online or by calling 1-800-MEDICARE. A Medicare representative can provide clarification and provide more specific instructions on filing an appeal.
If you have a Medicare Advantage plan, you will need to contact your insurance provider directly for more information. Keep in mind that the appeals process may be different when working with a private insurance company.
At this point, you should also contact your medical provider to put your bill on hold pending appeal. This way, you won’t be penalized financially while you’re waiting for the appeal to be processed.
Step 4: File an Appeal
There are five possible levels in a Medicare appeal. These include:
- Redetermination
- Reconsideration
- Administrative Law Judge Hearing
- Medicare Appeals Council Review
- Federal District Court Review
If you are unhappy with the decision made at any level, you can escalate the appeal to the next level within a designated time period. For example, if you are unhappy with your initial redetermination, you can escalate to a reconsideration.
The appeal starts with the redetermination process, where your claim will be reviewed by a Medicare Administrative Contractor (MAC). A MAC is a third-party health insurance provider who was uninvolved in the original claim and has been hired to review the case. To file this appeal, fill out the form on the last page of your MSN, following the instructions carefully.
This form must be sent in by the due date listed in the MSN, which is usually 120 days from the date of denial notice. Keep in mind that you can appoint a family member as a representative if you need assistance to submit the claim.
When submitting your appeal, you will need to create a written request explaining why you disagree with Medicare’s initial decision. This letter should include as many relevant details about your case as possible.
However, it’s still important to be concise and get your point across clearly. If possible, have a trusted friend or family member proofread the letter before you send it.
Step 5: Follow Up Regularly
The Medicare appeals process can take time, but it can help you avoid unnecessary medical bills in the long run. According to the Centers for Medicare and Medicaid, you should expect a decision on your determination 60 days after receiving your request in writing.
While waiting for your appeal to process, keep track of all correspondence with Medicare, and don’t be afraid to follow up periodically for more information.
What to Do If Your Claim Gets Denied Again
If your claim is denied after the initial appeal, you can escalate to the reconsideration level. If your claim continues to be denied, you can continue to escalate to Medicare hearings and even to court review.
The appeals process can be overwhelming, so don’t hesitate to seek guidance and support. You can get help from a senior insurance agent or legal professional who has experience with the Medicare system. Leaning on trusted family members or friends can also be helpful throughout this process.
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Get Medicare Support From Senior Insurance Agency
Appealing a Medicare claim denial may seem daunting at first, but it can lead to a successful outcome that saves you money. Taking the Medicare appeal process step-by-step will help it seem less overwhelming.
At Senior Insurance Agency, we’re here to help you navigate the Medicare system, from finding a policy to learning how to file a Medicare claim. We work with Medicare and Medicare Advantage in Carson City and throughout the state of Nevada.
Contact us today to learn more about our services.
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FAQs About Medicare Part A in Nevada
Most people pay $0 monthly for Part A, regardless of which state they are in. Those who did not pay Medicare taxes while working may need to pay a monthly premium for Part A.
Most people will have 100% of monthly premium costs covered with Part A. However, Medicare Part A does not cover 100% of your inpatient medical costs.
Emergency room visits are not considered inpatient care and are covered under Medicare Part B. However, Medicare Part A covers hospital stays that last more than one night.
Medicare Part A does not cover outpatient care or custodial care. It also does not cover inpatient services that happen outside of the United States.