How to Appeal a Denial of Medicare

If you have been denied Medicare coverage for a particular medical service or item, you have the right to appeal the decision. Here are the steps to appeal a denial of Medicare:

1. Review your Medicare Summary Notice (MSN): This is a document that shows all the services and items that Medicare has approved or denied. Check the MSN to confirm that the denial is correct.

2. Contact your healthcare provider: If you disagree with the denial, contact your healthcare provider and ask them to provide more information to Medicare about why the service or item is medically necessary.

3. Start the appeals process: To start the appeals process, you need to fill out a Medicare Appeals Request Form. You can get this form from your healthcare provider or by calling 1-800-MEDICARE.

4. Choose the type of appeal: There are five levels of appeal, and you need to choose which one you want to use. The five levels are:

  - Redetermination by Medicare contractor
  - Reconsideration by a Qualified Independent Contractor (QIC)
  - Hearing by an Administrative Law Judge (ALJ)
  - Review by the Medicare Appeals Council
  - Judicial review in a federal district court

5. Provide additional information: As you move through the appeals process, you may need to provide additional information to support your case. Be sure to keep copies of all documents related to your appeal.

6. Wait for a decision: Medicare has specific timelines for each level of appeal. You should receive a decision within 60 days of submitting your appeal request for redetermination and reconsideration. The time frames for the other levels of appeal may vary.

7. Keep appealing: If your appeal is denied at one level, you can appeal to the next level. Keep appealing until you get the decision you want.

Remember that you have the right to appeal a denial of Medicare coverage. If you need help with the appeals process, you can contact your State Health Insurance Assistance Program (SHIP) or the Medicare Rights Center.