What to Do If Medicare Denies a Claim
Getting a notice that Medicare denied a claim can be confusing, especially when you already received the medical care or believed the service was covered. A denial does not necessarily mean you have reached the end of the road. Depending on the reason for the denial and the type of Medicare coverage you have, you may be able to correct an error, ask for more information, or file an appeal.
The first step is figuring out exactly what Medicare or your Medicare plan decided and why.
Start by Reading the Denial
If you have Original Medicare, you generally receive a Medicare Summary Notice (MSN) every three months. The MSN lists the medical services and supplies Medicare processed during that period, what Medicare paid, what you may owe, and whether a claim was denied. It is not a bill.
If you have Medicare Advantage or a Medicare drug plan, you will receive notices directly from your plan explaining coverage or payment decisions.
Look for information such as:
The service or item that was denied
The date of service
The reason Medicare or your plan gave for the denial
The amount involved
Instructions for appealing
The deadline for filing an appeal
Keep the notice with your medical bills, receipts, and other paperwork related to the service.
A denial can happen for different reasons. Medicare or your plan may determine that a service is not covered, determine that certain requirements were not met, receive incorrect information from the provider, or determine that the amount billed is different from what it should have been.
The reason listed on your notice matters because it helps determine what you should do next.
Check With Your Doctor or Provider
Before immediately filing an appeal, contact the healthcare provider, hospital, facility, or supplier that submitted the claim.
Ask them to review the claim and confirm that they submitted the correct information. Medicare specifically recommends contacting the provider when an item or service is denied because the provider may be able to correct an error and resubmit the claim.
Ask questions such as:
Was the correct Medicare information submitted?
Was the correct billing code used?
Was the service submitted under the correct date?
Was the service submitted as medically necessary when appropriate?
Was any required documentation missing?
Can you correct and resubmit the claim?
Can you provide me with an itemized bill?
Can you give me medical records or other documentation that supports the service?
Keep notes about who you spoke with, when you called, and what they told you.
For example, suppose you had a procedure and Medicare denied the claim because information submitted by the provider was incorrect. The provider may be able to correct the information and resubmit the claim.
A corrected claim can resolve some problems without requiring you to go through the full appeal process.
If the Denial Is Correct, You Can Appeal
If you believe Medicare or your Medicare plan should have covered the service, you have the right to appeal certain coverage and payment decisions. You can appeal a decision about a service, supply, item, or drug that Medicare or your plan refused to cover or pay for. You can also appeal certain decisions about the amount you are required to pay.
Original Medicare
With Original Medicare, your Medicare Summary Notice explains how to appeal. The first level of appeal is called a redetermination.
Your MSN will provide the instructions and deadline for submitting the appeal. Medicare's current guidance generally gives you 120 days from the date you receive the Medicare Summary Notice to request a redetermination. Follow the specific deadline listed on your notice.
Your appeal should explain why you believe Medicare should cover or pay for the service. Include supporting documentation whenever possible.
Useful documentation may include:
A copy of the Medicare Summary Notice
Your medical records
A letter from your doctor
The doctor's explanation of why the service was necessary
An itemized bill
Relevant test results
Documentation from the provider
Other information that supports your claim
Make copies of everything you submit and keep proof that you sent the appeal.
Medicare Advantage
Medicare Advantage plans have their own appeal process. The first level is generally called a reconsideration.
You generally have 65 days from the date on the initial denial notice to request reconsideration. Your plan's denial notice will provide instructions for submitting the appeal.
The information you submit can include your name, Medicare Number, the service or item you're appealing, dates of service, the reason you disagree with the decision, and supporting documentation such as a doctor's statement.
If your health could be seriously harmed by waiting for a standard decision, you can ask for an expedited or fast appeal. Under Medicare Advantage rules, a fast appeal generally receives a decision within 72 hours when the requirements for an expedited appeal are met.
What Happens After You Appeal?
An appeal does not necessarily end after the first decision.
Original Medicare and Medicare Advantage both have multiple levels of appeal. If your first appeal is denied, your decision notice will explain whether you can move to the next level and what deadline applies.
For Medicare Advantage, there are five levels of appeal:
Reconsideration by your Medicare Advantage plan
Review by an Independent Review Entity
Review by the Office of Medicare Hearings and Appeals
Review by the Medicare Appeals Council
Judicial review in federal district court
The requirements and dollar thresholds can change as you move through the process.
For 2026, Medicare lists a $200 minimum amount for certain level 3 Medicare Advantage appeals and a $1,960 minimum amount for certain level 5 appeals.
Original Medicare also has five levels of appeal. Your decision letter will tell you how to continue if your appeal is denied.
The important part is to read each decision carefully. Every level comes with its own instructions and deadlines.
Get Help With the Appeal
You do not have to figure out the Medicare appeals process completely on your own.
The State Health Insurance Assistance Program (SHIP) provides free, personalized Medicare counseling. SHIP counselors can help you understand your Medicare coverage and appeal rights. Medicare provides a tool for finding your state's SHIP program.
You can also contact Medicare at 1-800-MEDICARE (1-800-633-4227) for questions about Medicare coverage and appeals. TTY users can call 1-877-486-2048.
You can appoint someone you trust to help with an appeal. This could be a family member, friend, caregiver, or another person you choose. Medicare has procedures for appointing a representative who can help with your case.
If you have Medicaid or another type of health coverage in addition to Medicare, that coverage may also be involved in paying your claim. The order in which different insurance programs pay can affect what happens after Medicare processes a claim.
Keep Good Records
Medical bills and insurance paperwork can pile up quickly, so create a simple system for keeping track of a denied claim.
Keep:
Information | What to Record |
Date of service | When you received the service |
Provider | Doctor, hospital, facility, or supplier |
Service | What you received |
Claim number | Number listed on your Medicare or plan notice |
Reason for denial | Exact explanation provided |
Date you contacted provider | When you called or wrote |
Person you spoke with | Name and department |
What they said | Important instructions or corrections |
Appeal deadline | Date your appeal must be received |
Appeal submitted | Date and method you submitted it |
Confirmation | Tracking number, fax confirmation, online confirmation, or other proof |
Decision | Result of the appeal |
Next deadline | Deadline for the next level if you continue |
Keep copies of your notices, bills, medical records, letters, appeal forms, and correspondence. If you speak with someone by phone, write down the date, time, person's name, and what you were told.
A simple folder, binder, or digital folder can make a complicated claim much easier to follow.
Final Thoughts
A Medicare denial gives you information about a coverage or payment decision. Start by reading the notice, checking the reason for the denial, and contacting the provider to see whether an error can be corrected.
When you believe Medicare or your Medicare plan should have covered the service, an appeal gives you a formal way to ask for the decision to be reviewed. Pay close attention to the deadline on your notice and keep copies of everything you submit.
Medicare's official appeals information is available here: Medicare Appeals and Claims Information
Up Next: Medicare coverage can be valuable, but healthcare costs can still be difficult to manage on a limited income. Medicaid may provide additional assistance for people who meet certain financial and eligibility requirements.
In the next article, we'll look at What Happens When A Doctor Doesn't Accept Your Plan.
Pardon our ads, they allow us to keep our site running and keep our helpful content free to access.
Comments