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

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

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Dear Toni,

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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.

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Thanks,

Joey from Cleveland, OH

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Hello Joey,

Encountering an issue with a doctor 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.

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The first step in this process is to visit www.medicare.gov and create an account to view your Medicare information and medical claims. 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 and contain information on submitted charges, the amount paid by Medicare, and the amount for which you are responsible. MSNs are used exclusively with Original Medicare, not with Medicare Advantage or Medicare Part D Prescription Drug Plans.

Below is what you should do if you believe the claim is medically necessary: 

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.

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

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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. 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.

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

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Originally published June 05, 2023

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