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Why did Medicare deny my claim?

Vintage / retro style : Fountain pen, a chest-piece of a stethoscope and a medical benefits claim form on a clipboard. A blank / empty form is waiting to be completed and signed by an insured person.

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Just the Essentials…

  • On rare occasion, Medicare may deny claims for a variety of reasons.

  • When this happens, you will receive a Medicare denial letter to notify you that a claim was denied.

  • There are four main types of denial letters, which differ depending on why your claim was denied.

  • Luckily, there are ways you can appeal Medicare’s decision to deny your claim if you feel it was denied in error.

  • Appealing the decision quickly and with as many supporting details as possible is your best shot at overturning the decision.

What does it mean if Medicare denied my claim?

Though Medicare is designed to give seniors and certain disabled individuals the most unobstructed access to healthcare possible, there are some rare circumstances that may unfortunately lead to a Medicare claim denial.

When a Medicare claim is denied, you will receive a letter notifying you that a specific service or item is not covered or no longer covered. This can also happen if you are already receiving care but have exhausted your benefits.

There are four main types of Medicare denial letters that you may receive depending on the specific reasoning behind your claim’s denial. At MedicareInsurance.com, we’re here to help you take a closer look at why your Medicare claim was denied and what you might be able to do about it going forward.

Why did Medicare deny my claim?

Medicare may deny your claim based on a few different factors. The exact reasoning behind your denied Medicare claim will be explained to you in the context of your denial letter. Learn more about the four main types of denial letters right here.

Generic Notice or Notice of Medicare Non-Coverage

You may receive a Notice of Medicare Non-Coverage if you have received or currently are receiving care from an outpatient rehabilitation facility, home health agency, or skilled nursing facility that is not covered by your Medicare package.

If for whatever reason, the services you received or are currently receiving from these providers is not covered, Medicare may first notify your medical provider, who then contacts you. In any event, you must be notified at least two calendar days before services end.

Skilled Nursing Facility Advanced Beneficiary Notice

This type of denial letter is intended to notify you that an upcoming healthcare service or item received via a skilled nursing facility will not be covered by Medicare.

Typically, this occurs when Medicare determines that the service or item in question is not medically reasonable or necessary. In some cases, the service or item may also be deemed “custodial,” meaning that is not medical-related and thus, won’t be covered.

You may receive this notice in the event that you are getting close to meeting or exceeding you’re allowed days under Medicare Part A.

Fee-for-Service Advanced Beneficiary Notice

A Fee-for-Service Advanced Beneficiary Notice is issued when Medicare has denied certain services under Medicare Part B. Some examples of services and items that may be denied include therapy, medical supplies, and laboratory tests that are not considered to be medically necessary.

Notice of Denial of Medical Coverage (Integrated Denial Notice)

This type of Medicare denial letter is issued specifically for Medicare Advantage and Medicaid beneficiaries. An Integrated Denial Notice may be issued when your specific Medicare Advantage plan or Medicaid is denied in whole or in part.

This may occur if Medicare has recently discontinued or reduced types of treatment, services, or items that were previously authorized for coverage.

What can I do if Medicare denies a claim?

If you feel that Medicare has made in error in denying your coverage, you are welcome to appeal the decision. Some scenarios in which an appeal may be justified include denied claims for services, prescription drugs, lab tests, or procedures that you do believe were medically necessary.

The manner in which you may file an appeal often depends on which part of Medicare your claim falls under. Here’s how to appeal a denied Medicare claim depending on the parts of Medicare involved.

Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance)

To appeal a denied Medicare Part A or Medicare Part B claim, you must start the appeal process within 120 days of initial notification. You will use the Medicare Redetermination Form to file your claim. If the appeal is denied, you will need to move on to level 2 reconsideration.

Medicare Part C (Medicare Advantage)

To appeal a Medicare Part C denial, you must initiate the process within 60 days of initial notification. Each Medicare Advantage plan will have its own process for appealing coverage denials, and your plan must notify you of this process.

Typically, this appeal process will take between 30 and 60 days to review. However, if you need an answer more quickly, you can also apply for an expedited review.

If your Medicare part C appeal is denied, you can move forward to level 2 and level 3 appeals, which are handled by the Office of Medicare Hearings and Appeals.

Medicare Part D (Prescription Drug Coverage)

The appeal process for a Medicare Part D denial must be initiated within 60 days of initial notification. You can request special exception from your drug plan, or you may request redetermination (appeals level 1).

If this appeal is denied, you must request further reconsideration from an Independent Review Entity to take your case further.

What are the key things to remember when considering a Medicare denied claim appeal?

If you decide to appeal, be sure to ask your doctor, health care provider, or medical supplier for any relevant information that may help your case. In addition, take the time to review your coverage plan and your denial letter thoroughly.

Additionally, you may wish to contact your plan for more details regarding what is and is not covered under your Medicare package. You can find your plan’s contact information on your plan membership card or by searching for it online.

Remember to write your Medicare Number on all documents you submit with your appeal request and to keep a copy of everything you send to Medicare for your own records.

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