Many individuals face challenges when their Medicare claims are denied, but understanding the appeal process can significantly improve the chances of overturning those decisions. If you disagree with a coverage or payment decision from Medicare, appealing the decision is a viable option, and statistics show that many appeals are successful.
Before proceeding with an appeal, it is advisable to contact your healthcare provider, hospital, and Medicare to identify any potential issues with the claim. Often, denials result from simple billing errors, which can be resolved without the need for a formal appeal.
Understanding the Medicare Appeals Process
If your claim denial remains unresolved, the next step is to initiate an appeal. For those under original Medicare, it begins with your quarterly Medicare Summary Notice (MSN). This document outlines all billed services, supplies, and equipment related to your medical treatment, along with reasons for any denials. You can also access claims online at MyMedicare.gov or by calling 800-633-4227.
Original Medicare offers a structured five-level appeals process. If you are receiving services from a hospital or skilled nursing facility and those services are about to end, you can request a “fast appeal.” You have 120 days from the date of the MSN to file a “redetermination” request with a Medicare contractor, who will review your claim.
To appeal, highlight the disputed items on the MSN, provide a written explanation for why you believe the denial should be reversed, and include supporting documents such as a letter from your healthcare provider. Send this documentation to the address indicated on the MSN.
Alternatively, you can use the Medicare Redetermination Form, which is available at CMS.gov or by contacting Medicare directly. Typically, the contractor will make a decision within 60 days of your request. If the initial appeal is denied, you can request a reconsideration by another reviewer, and if the disputed charges exceed $190 in 2025, you may request a hearing with an administrative law judge. Such hearings are often conducted via videoconference or teleconference.
For claims reaching this level, if denied, you can escalate your appeal to the Medicare Appeals Council and, for disputes exceeding $1,900 in 2025, pursue judicial review in a U.S. District Court.
Appealing Medicare Advantage and Part D Decisions
For those enrolled in a Medicare Advantage health plan or a Part D prescription drug plan, the appeals process varies slightly. Importantly, you only have 65 days to initiate an appeal, and you must appeal directly to the private insurance plan rather than Medicare.
If you believe that your health is at risk due to the plan’s refusal, you can request an expedited appeal. Under these circumstances, Part D insurers must respond within 24 hours, while Medicare Advantage plans have 72 hours to provide a response. Similar to original Medicare, the appeal process consists of five levels, allowing you to escalate any decision you disagree with.
For additional guidance on filing Medicare appeals, visit Medicare.gov/claims-appeals and select “File an appeal.” It is crucial to maintain detailed records of all communications with Medicare regarding your denial, whether written or oral.
If you require assistance with your appeal, consider appointing a representative such as a relative, friend, or attorney. Alternatively, you can reach out to your local State Health Insurance Assistance Program (SHIP), which offers free counseling and support in filing appeals. To locate your nearest SHIP, visit ShipHelp.org or call 877-839-2675.
Taking these steps can enhance your chances of successfully navigating the Medicare appeals process and securing the coverage you need.
