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September 26, 2023

What to do if your Medicare claim is denied

  • Medicare coverage policies can lead to a large number of denied claims each year, amounting to significant denied spending.
  • Many of these denials can be appealed by patients or their healthcare providers.
  • It is important to understand the appeals process for denied claims and to seek assistance from a counselor or advisor if needed.
Denied Medicare Claim? Don't Panic – Here's your Roadmap to Reimbursement

The number of Medicare claims denied each year varies. From 2014 to 2019, denied claims in both Medicare and Medicare Advantage amounted to $416 million in denied spending.

As a Medicare beneficiary, it can be frustrating to receive a denial on a claim you thought would be covered. However, a claim denial does not necessarily mean the end of the road. Here are some steps you can take if your Medicare claims are denied:

  1. Understand the reason for the denial: The first step is to review the explanation of benefits (EOB) statement you received from Medicare or your insurer. This statement will explain the reason for the denial. It could be due to a number of issues, such as lack of medical necessity, coding errors, or incomplete documentation. Understanding the reason for the denial is important as it will guide you on the next steps to take.

  2. Appeal the decision: If you disagree with the reason your claim was denied, you have the right to appeal the decision. You can submit an appeal either in writing or online. Your appeal should include a letter explaining why you believe your claim should be covered and any supporting documentation you may have. Make sure you submit your appeal within the required timeframe.

  3. Seek help from a Medicare counselor or advocate: If you are unsure of how to appeal or need assistance in navigating the appeals process, you can get help from a Medicare counselor or advocate. Medicare counselors are trained volunteers who offer free, impartial advice on Medicare-related issues, including appeals. You can locate a Medicare counselor in your area by contacting your state health insurance assistance program (SHIP).

  4. Consider filing a complaint: If you have concerns about a billing or payment issue, you can file a complaint with Medicare. Medicare will review your complaint and take steps to address the issue. You can file a complaint by phone, mail, or online.

  5. Be persistent: Appealing a claim denial can sometimes be a lengthy process, but don't give up. Medicare beneficiaries have the right to appeal up to five levels of review, including an administrative law judge hearing and Medicare Appeals Council review. Keep in mind that if your appeal is unsuccessful, you may be responsible for paying for the services you received.

In conclusion, receiving a denial on a Medicare claim can be frustrating, but it's not the end of the road. By understanding the reason for the denial and taking the appropriate steps, you can increase your chances of having your claim approved. Don't hesitate to seek help if you need it, and be persistent in your efforts to appeal the decision.

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