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.
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.
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.
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:
Another option is to file a Form 20027, Medicare Redetermination Request Form. If you need help filing your appeal, you can call 800-MEDICARE or contact your State Health Insurance Assistance Program (SHIP).
You’ll generally get a decision, called a Medicare redetermination notice, from the administrative contractor within 60 days after receiving your request. If your claim is approved, it will be listed on your next Medicare summary notice.
Yes, if Medicare denies your redetermination request, you have the right to pursue up to four more levels of appeals. The notice you receive with the decision at each level includes instructions for pursuing the next level of appeal.
Level 2, reconsideration
Level 3, Office of Medicare Hearings and Appeals
Level 4, Medicare Appeals Council
Level 5, judicial review
These steps are for appealing claims decisions in original Medicare and don’t apply to claims filed through a private Medicare Advantage plan or a Part D prescription plan — although the process is similar.
A company’s officials review your appeal in Level 1, redetermination. After that, an independent review entity that solicits responses from your insurer as well as potential providers of your services and supplies is involved in Level 2. The remaining levels are the same as for original Medicare.
If your claim involves a prescription drug or service that you need now and can’t wait to receive as you go through the appeals process, you can request an expedited appeal. Review the denial notice or contact your plan for more information about the steps and deadlines for filing an appeal.
Published December 2, 2022
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