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Appealing a Medicare Claim Decision

Why, when and how to challenge a denial of benefits

If you disagree with a decision about one of your Medicare claims, you have the right to challenge that decision and file an appeal.

Situations in which you can appeal include:

  • Denials for health care services, supplies or prescriptions that you have already received. For example: During a medical visit your doctor conducts a test. When the doctor submits a claim to be reimbursed for that test, Medicare determines it was not medically necessary and denies payment of the claim.

  • Denials of a request you or your doctor made for a health care service, supply or prescription. For example: Medicare determines that a wheelchair is not medically necessary for your condition.

  • Denials of a request you and your doctor have made to change the price you pay for a prescription drug. For example: Your Medicare Part D drug plan rejects your doctor’s recommendation that you receive a discount on an expensive medication because the available lower-cost drugs are not effective for your condition.

The time limits and requirements for filing an appeal vary depending on which part of Medicare (A, B, C or D) you are appealing.

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