Denied by Medicare? Here’s How to Appeal Your Refusal

Dear Toni,

I recently received a cardiologist bill of $2,000, which Medicare is refusing to cover. Despite enrolling in Medicare and its supplement for the freedom of choosing my doctor, I’m now lost amid a slew of confusing regulations.

I’m hoping to seek advice on what to do next, as this matter seems too complex for me to navigate on my own.

Thanks,

Joey

Hello Joey,

Encountering an issue with a doctor’s or provider’s bill is a rare occurrence, but when it does happen, there is a process that must be followed to determine whether an office visit or procedure will be paid for as a “Medicare-approved” service. Fortunately, I have the steps and information that can help you get to the bottom of this!

Step One: Visit the Medicare.gov website.

The first step in this process is to visit www.medicare.gov and create an account to view your Medicare information and medical claims.

To create an account:

1. Scroll down and click “Log In/Create Account.”
2. Click “create an account” on the right-hand side of the screen.
3. Enter your Medicare information. You will need your red, white, and blue Medicare card and your Part A coverage start date.
4. Type in the rest of your information, including your birth date, zip code, last name, and email address.
5. Create a username and password.

⚠️If you are unable to open an account, you can wait until you receive your Medicare Summary Notice (MSN). Please note that the MSN is not a bill. ⚠️

Medicare Summary Notices (MSNs) are sent out four times a year. It contains the following information:

• All your services or supplies that providers and suppliers billed to Medicare during that period
• What Medicare paid
• The maximum amount you may owe the provider

Please note: MSNs are used exclusively with Original Medicare, not with Medicare Advantage or Medicare Part D Prescription Drug Plans.

Step Two: Contact your doctor’s billing office.

If you suspect an error in your Medicare billing, it’s possible that the medical provider may have used the wrong CPT/HCPCS codes when submitting your claim. This can lead to Medicare denials, but it’s often easily resolvable, especially when the correct codes are used.

To confirm the coding issue…

Ask your doctor’s billing office to reach out to 800-MEDICARE (800-633-4227) to verify the correct submission. In case a wrong code was used, request your doctor to submit the claim afresh with the correct code(s).

Step Three: File an appeal.

If the medical provider is unwilling to resubmit the claim or believes that it was correctly coded, the next step is to file an appeal. Filing appeals is a straightforward process, and the MSN (Medicare Summary Notice) has clear instructions on how to do it.

To file an appeal:

• Circle the specific item on the MSN that you want to appeal.
• Write “Please Review” on the bottom, sign the back, and
• Mail the original to Medicare at the address listed on the MSN.
• Ensure that you file your appeal within 120 days of receiving the MSN.

If possible, it helps to have your healthcare provider write a letter detailing why the service was necessary. This can be sent along with your MSN to support your claim. According to Medicare.gov, you can also get assistance with filing an appeal from:

• State Health Insurance Assistance Program (SHIP): To receive assistance, simply visit shiphelp.org and find your local office. From there, you can get FREE personalized health insurance counseling. These state programs get money from the federal government to give free local health insurance counseling to people with Medicare (per Medicare.gov).
• Representative: If you trust a family member or friend, you can appoint them as your representative! This can also be an attorney, financial advisor, doctor, or anyone within your circle you trust to make decisions on your behalf.

To appoint a representative, simply:

1. Fill out an “Appointment of Representative” form. You can download different versions of this form at CMS.gov/Medicare/CMS-Forms/CMS-Forms-Items/CMS012207.
2. Send the completed form with your appeal to the Medicare Administrative Contractor (MAC) (a company that handles Original Medicare claims) that’s listed on your Medicare Summary Notice (MSN), or your Medicare health plan.

Or…

1. Submit a written request that includes:
   • Your name, address, phone number, and Medicare Number.
   • A statement that appoints someone as your representative.
   • The name, address, and phone number of your representative.
   • The professional status of your representative (such as a doctor or attorney) or their relationship to you.
   • A statement authorizing the release of your personal and identifiable health information to your representative.
   • A statement explaining why you’re being represented and to what extent. 

⚠️ Always keep photocopies and records of all communication, whether written or oral, with Medicare concerning your denial. Send your appeal by certified mail and make sure you ask the post office or UPS/FEDEX for a signed delivery confirmation. ⚠️

What Can You Appeal Under Medicare?

According to patientadvocate.org, you can appeal several different items under Medicare. These include:

• A healthcare service, supply, item, or prescription drug to which you believe you’re entitled.
• Payment for a healthcare service, supply, item, or prescription drug to which you believe you’re entitled.
• You can also request a change in the amount you have to pay for the aforementioned items.

Additionally, according to Medicare.gov, you can also file an appeal if your plan refuses to:

• Medicare or your plan stops providing or paying for all or part of a health care service, supply, item, or drug you think you still need.
• Your plan’s drug management program labels you as “at-risk” due to you meeting the Overutilization Monitoring System criteria. This means your plan limits your access to coverage for drugs like opioids and benzodiazepines.
  

More Medicare Resources

I hope this helped shed a little clarity on your situation, Joey! If you or any other readers have any questions, simply call the Toni Says Medicare hotline at 832-519-8664 or email [email protected]. Toni’s new “Confused about Medicare” video series is available at www.tonisays.com. And remember, readers—with Medicare, what you don’t know WILL hurt you.

For more great articles like this one, visit our Medicare Blog!

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