Many individuals experience frustration when facing a denial of coverage from Medicare. If your claim has been denied, it is possible to appeal the decision, and a significant number of appeals are successful. Before proceeding with an appeal, it is advisable to communicate with your healthcare provider and Medicare to identify any potential errors in billing that could have led to the denial. Often, simple mistakes in coding can be resolved without the need for a formal appeal.
Understanding the Appeals Process for Original Medicare
If you have Original Medicare, the first step is to review your quarterly Medicare Summary Notice (MSN). This document outlines the services billed to Medicare and provides details on any denied claims. You can also access your claims information online at MyMedicare.gov or by calling the Medicare helpline at 800-633-4227.
The appeals process for Original Medicare consists of five levels, starting with a “redetermination” by a Medicare contractor. You have 120 days from the date you receive your MSN to initiate this request. To do so, highlight the disputed items on the MSN, include a written explanation of your disagreement, and attach supporting documents, such as a letter from your healthcare provider justifying the coverage. Send this information to the address specified on the MSN.
Alternatively, you can complete the Medicare Redetermination Form, which can be downloaded from CMS.gov or requested via mail by calling 800-633-4227. The contractor typically makes a decision within 60 days of receiving your appeal. If the decision is unfavorable, you can request a “reconsideration” from a different reviewer and provide additional evidence.
In cases where the disputed charges exceed $190 in 2025, you may appeal to an administrative law judge. This hearing can be conducted via videoconference or teleconference. If further appeal is necessary, you may take your case to the Medicare Appeals Council, and for claims of at least $1,900, the final level of appeal is a judicial review in a U.S. District Court.
Appealing Medicare Advantage and Part D Decisions
For those enrolled in a Medicare Advantage health plan or a Part D prescription drug plan, the appeals process differs slightly. You have only 65 days to initiate an appeal, and must first address the issue with your private insurance provider rather than Medicare. If the denial impacts your health, you can request an expedited appeal, which requires a response from Part D insurers within 24 hours and from Medicare Advantage plans within 72 hours.
Similar to Original Medicare, these plans offer five levels of appeal. If you disagree with a decision at any level, you can escalate the appeal accordingly. Detailed information and step-by-step guidance on filing an appeal can be found at Medicare.gov under the “File an appeal” section.
It is crucial to maintain thorough records of all communications with Medicare, including both written and oral exchanges, regarding your denied claim.
If you require assistance with the appeals process, consider appointing a representative such as a family member, friend, or advocate to help you navigate the steps. You can also reach out to your local State Health Insurance Assistance Program (SHIP), where counselors are available to assist with appeals at no cost. To find your local SHIP, visit ShipHelp.org or call 877-839-2675.
For additional questions or concerns, individuals can contact the Savvy Senior service directly at [email protected] or mail inquiries to Savvy Senior, P.O. Box 5443, Norman, OK 73070.
