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First, know that you have the right to appeal if Medicare denies your claim. The process, which has up to five levels of appeals, has specific instructions and time frames for each step.
What steps should I take if I disagree with a claim decision?
With original Medicare, you may be able to solve some Medicare claims issues without going through the appeals process.
When you have a question about a claim, first review your Medicare summary notice (MSN), which lists all services and supplies that providers billed to Medicare on your behalf. Medicare sends this notice to enrollees every three months and breaks out claims for Medicare Part A and Medicare Part B separately.
The first page summarizes all claims and costs for the period, adding this statement: “Did Medicare approve all claims?” It also shows how much of the annual deductible you've paid already. So even if your claim was approved, you may owe money if you haven’t met your deductible.
The third page has details about the claims, including dates, whether a claim was approved, charges not covered, the amount Medicare paid and the maximum amount you may be billed.
Your online Medicare account has updates more frequently than the paper version. You can access information within 24 hours after a claim is processed.
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If your claim was denied or you disagree with the amount you may be billed, contact the provider — a phone number is on the notice — and ask for further itemization for the claim. Confirm the provider sent the right information to Medicare, and if some of the details are wrong, ask the provider’s billing office to contact Medicare and correct the errors.
How do I file an appeal for my claim?
If you still disagree with the claim decision as an original Medicare beneficiary, you have 120 days after receiving the MSN to file an appeal.
The last page of your notice lists the date that the Medicare claims office must receive your appeal. This level is called redetermination, meaning a Medicare administrative contractor not involved in the initial claim decision will review your claim.
You must file your appeal in writing. The last page of the MSN lists the steps to take:
- Circle the services or claims you disagree with on the MSN.
- Explain in writing why you disagree with the decision. Include your explanation on the notice, or attach a separate page to the notice if you need more space.
- Fill in your own or your authorized representative’s full name, phone number and your Medicare number.
- Include any other information about your appeal. You can ask your doctor, health care provider or supplier for information that will back up your claim and help your case. Write your Medicare number on all documents that you send and make copies for your records.
- Mail the notice and all supporting documents to the address listed on the last page of your MSN.
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