If Original Medicare will not pay for care you received and you think the care you received is medically necessary, you should not take no for an answer.
If you are in Original Medicare, the appeals process for Part A and Part B denials is as follows:
Receive a Medicare Summary Notice (MSN) once every 3 months in the mail.
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You notice that Original Medicare has not paid the Medicare-approved amount for a service listed on your Medicare Summary Notice.
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Appeal to Original Medicare by circling the service in question, writing "please review" on the MSN, signing the bottom, and sending it back to Medicare at the address indicated. A letter of support from your doctor or other health care provider stating the service was medically necessary is useful to send to Medicare as well. Make copies of everything you send. Be sure to send this appeal no later than 120 days (4 months) after you receive the original Medicare Summary Notice.
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Medicare continues to deny the service.
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Medicare agrees the service was medically necessary
Medicare pays for the the service.
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You can appeal again by asking for a reconsideration by the the independent body that reviews Medicare appeals claims. Send in all the information you sent at the intial appeal. You must file a reconsideration within 180 days (6 months) of receiving the initial MSN.
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Reviews uphold Medicare's denial of the claim. |
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Reviewers agree the service was medically necessary.
Medicare pays for the service
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Request an Administrative Law Judge (ALJ) Hearing within 60 days of receiving the last denial of coverage from Medicare. The amount in question must be at least $140 (in 2013).
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Please note, if you are turned down at the ALJ level, you can appeal to the Medicare Appeals Council (MAC) and then to federal court. If you plan to appeal at the Administrative Law Judge (ALJ) level or higher, you may want to find an advocate or lawyer to help you.
