Medicare claims contain specific codes that describe the different types of services, diagnoses, and purpose for the service. Depending on the type of service you receive, the claim may require several codes. These codes help the doctor communicate with Medicare, so Medicare knows how to pay the claim.
Medicare covers services and items that are medically necessary to diagnose, treat, and prevent illnesses and conditions. However, if your doctor performs a service and doesn’t provide accurate codes to prove why the service was medically necessary, Medicare may deny the service, leaving you with 100% responsibility for the bill.
Medicare may deny services for other reasons, even if the claim includes all the correct codes. If your doctor performs a non-medically necessary service, Medicare will deny it. Either way, you have the option to appeal a Medicare decision.
First steps to filing a Medicare appeal
If you receive a bill from your doctor’s office including charges you weren’t expecting, Medicare may have denied part or all of the claim. Before paying the bill, you should investigate further to make sure you owe the amount billed to you. Medicare approves the majority of claims sent to them. Therefore, if you receive a bill for uncovered services, there’s likely a good explanation.
First, you should review your Medicare Summary Notice (MSN). MSNs are mailed to Original Medicare beneficiaries once every three months. Your MSN shows services billed to Medicare on your behalf during the past three months. Next to each service, you will see whether Medicare covered it. If a service is denied, the MSN will also include a brief explanation of the denial.
Note that if you are enrolled in Medicare Advantage, you won’t receive an MSN. Instead, you’ll receive a denial notice from your plan’s carrier.
Once you have reviewed your MSN or denial notice, contact your doctor’s office for any other documents from the day of service, such as the original claim and doctor’s notes. The more documents you can provide Medicare to prove your case, the better your chances of winning the appeal
Next steps to filing a Medicare appeal
Once you have compiled all the necessary documents, it’s time to actually file your appeal. To file a Medicare appeal, you must fill out a form and write a letter explaining why you think your service should be covered.
You will need to fill out the appeals form found on the last page of your MSN. If for some reason you don’t have your MSN or you simply want to cover your bases, you can also fill out a redetermination request form from the Medicare website here. Mail your completed forms, letter, and other documents to the Medicare Claims Office address found at the bottom of your MSN.
If you have a Medicare Advantage plan, you’ll send your appeal to the address provided by your carrier on your denial notice, not to the Medicare Claims Office. If you’re unsure where to send your documents, call your plan’s member services department.
Final steps to filing a Medicare appeal
After you’ve completed the above steps, your wait begins. Medicare has up to sixty days to approve or deny your appeal. You will get a Medicare Redetermination Notice once a decision is reached. If you have a Medicare Advantage plan, your carrier has up to sixty days, depending on the type of appeal, to issue a decision. However, you may be able to have your appeal expedited.
If your appeal is approved, no further action is needed on your part. On the other hand, if Medicare denies your appeal, you can choose to escalate your appeal to the next level or simply pay your bill. You can find instructions for your next steps on your denial letter if you decide to escalate your appeal.
Additional appeal tips
Be sure to write your Medicare ID number on top of each document you mail to Medicare. That way, if any of your documents get misplaced, the Medicare representative can easily figure out where they belong.
You should also make copies of everything you mail into Medicare; it’s good practice regardless of the situation. Also, be sure you file your appeal within four months of receiving your MSN, or two months within getting your Medicare Advantage plan denial letter.
The appeal process can be time-consuming and frustrating, but these steps and tips can help make the process as smooth as possible.