Appealing a Medicare Claim Decision

Why, when and how to challenge a denial of benefits

by: Education & Outreach, from: AARP, Updated 2012

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:

Appealing a Medicare Claim v. Questioning a Medicare Claim

If your Part A or Part B Medicare Summary Notice (MSN) shows that payment has been denied for a claim you think Medicare should have paid, follow the appeal steps described in this article.

However, if Medicare has approved and paid for a service you didn’t receive, or you see a charge you believe is an error or possible fraud, contact the billing hospital, facility or doctor’s office.

If you still have questions about a claim you think Medicare should not have paid, report your concerns to the Medicare at 1-800-MEDICARE.

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.