I rarely see a problem with doctor or provider bills, but when it does happen, there is a process you must follow to find out if the office visit or procedure will be paid as a Medicare-approved service.
If Original Medicare will not pay for the care you received, you will find this out when you receive your Medicare Summary Notice (MSN). The MSN is a summary of claims for health care services Medicare processed for you during the last three months. The MSN is not a bill. It’s mailed four times a year and contains information on submitted charges, the amount that Medicare paid, and the amount you are responsible for. MSNs are used only with Original Medicare and not with Advantage or Part D Prescription Drug plans.
How to Appeal Medicare’s Decision to Not Pay
Below is what you should do if you believe your claim is for a medically necessary service.
- First, find out if it’s possible that there was a billing mistake. Medicare uses a set of service codes, called CPT codes, for processing medical claims. Each medical service has been assigned a specific code. Sometimes providers accidentally use the wrong codes when filling out paperwork. This would result in a denial. This can sometimes be easily resolved by simply asking your doctor to double-check that your claim was submitted with the correct codes. If the wrong code was, in fact, used, then your doctor’s billing office can call 800-MEDICARE (800-633-4227) to get in touch with the company that processes claims. From there, the error can be corrected.
- If the provider believes that the claim was correctly coded or is unwilling to refile the claim, your next step is to appeal. Appealing is easy and many Americans win! The MSN will have instructions for how to appeal. Follow these instructions or call 1-800-MEDICARE for help. If the MSN lists several items and you are not disputing all of them, then circle the one you want to appeal. Write, “please review” on the bottom and sign the back. Make a copy for your files. Then, mail the signed original to Medicare at the address on the MSN. Make sure you mail your appeal within 120 days of receiving the MSN. Do NOT wait any longer!
- If possible, get a letter from your healthcare provider saying that you needed the service and why. Send this with your MSN.
Toni Says: 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 parcel service for signed delivery confirmation.
Toni KingContributing Writer
Toni King is an author, columnist, and radio and TV personality who specializes in Medicare, Social Security, and long-term care planning. While conducting a Medicare workshop in 2009, Toni was approached by a member of the audience who had received incorrect information about his Medicare Part B enrollment from Social Security. After taking a couple of days to help the gentleman straighten out his overwhelming problem, Toni’s new mission had become clear. Following more than 27 years as a top sales leader in the Medicare insurance industry, Toni would become an advocate for Americans receiving Medicare. Since then, Toni has devoted her life and career to putting Medicare into “people terms” with the help of her books, consultations, workshops, and website, ToniSays.com. Read more from Toni King.