Medicare Coverage Denials: Reading the Notice

When Medicare or a Medicare plan says it will not pay for a service, the news usually arrives on paper. The notice can look dense, but it holds the information you need: what was denied, why, and how to appeal. Reading it closely is the first step.

This guide explains the main notices people see and how the appeal process is generally organized. It follows the information that Medicare and the Centers for Medicare & Medicaid Services (CMS) publish. Your notice controls the details of your case.

First, know which kind of Medicare you have

The appeal path depends on your coverage. The Medicare appeals page separates three groups:

• Original Medicare (Part A and Part B, run directly by Medicare).
• Medicare health plans, such as Medicare Advantage plans.
• Medicare drug plans (Part D).

If you are in a Medicare Advantage plan or a drug plan, Medicare says the plan must tell you in writing how to appeal. Check your plan materials or call the plan.

The Medicare Summary Notice (Original Medicare)

If you have Original Medicare, the key document is usually the Medicare Summary Notice (MSN). It lists services billed to Medicare, what Medicare paid, and what you may owe.

When reading an MSN, look for:

• Each service and its date. Check that you actually received what is listed.
• Whether Medicare approved the claim. A denied item is marked on the notice.
• The reason code or explanation. This tells you why the item was not paid.
• The appeal deadline. Medicare says you must file your first appeal by the date shown in the MSN.
• The address for appeals. Medicare says the claims office address is on the last page of the MSN.

Medicare describes two ways to start a first-level appeal, called a redetermination. You can fill out a Redetermination Request Form. Or you can circle the item on a copy of your MSN, explain in writing why you disagree, add your name, contact details, and Medicare Number, and mail it to the address listed. Details are on the Original Medicare appeals page.

Denial letters from a Medicare Advantage plan

Medicare Advantage plans make their own coverage decisions, called "organization determinations." If the plan denies a service, you get a written notice.

According to Medicare's page on health plan appeals, you, your representative, or your doctor must generally file the first appeal within 65 days from the date on the plan's denial notice. If you miss the deadline, you must explain why you filed late.

The appeal should include your name, address, Medicare Number, the services and dates you are appealing, and why. Medicare also notes that if waiting the standard 30 days could seriously harm your health, you can ask for a fast, or "expedited," appeal. If the plan agrees, or your doctor says so, the plan must decide within 72 hours.

The Advance Beneficiary Notice (ABN)

Sometimes you get a notice before you receive a service. The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is given by providers and suppliers to people with Original Medicare when they expect Medicare to deny payment.

An ABN is not a denial by Medicare. It is the provider's warning that Medicare may not pay. It asks you to choose whether you still want the service and to understand you may be responsible for the cost. Read the options on the form carefully before you sign, and keep a copy.

How the appeal levels work

Medicare says there are generally five levels of appeal. If you disagree with a decision at one level, you can usually go to the next. At each level, you get a decision letter explaining how to move forward.

For Original Medicare, Medicare's page explains:

1. Redetermination by the Medicare Administrative Contractor (MAC). You generally get a decision within 60 days after the MAC receives your appeal.
2. Reconsideration by a Qualified Independent Contractor (QIC). You have 180 days after you get the MAC's decision letter to ask for this.
3. Further levels follow, with instructions in each decision letter. A later level can lead to review in federal court if the amount meets a minimum set each year.

Read each letter as it arrives. The next deadline is usually printed there.

Building a stronger appeal

Medicare suggests asking your provider or supplier for any information that could make your appeal stronger. Useful items often include:

• A letter from your doctor explaining why the service was needed.
• Medical records that support the need.
• A copy of the denial notice or MSN with the item marked.

Write down who you spoke with, when, and what they said. If you miss a deadline because of illness, disability, or an accident, Medicare says you may still get a decision if you can show good cause.

Where to get help

• SHIP counseling. Medicare points to State Health Insurance Assistance Programs, which give free, personal counseling to people with Medicare.
• A representative. Medicare explains you can appoint a trusted family member or friend to act for you.
• A lawyer. Some people talk to a lawyer when a denial is large, involves ongoing care, or overlaps with an injury claim or a medical malpractice question.

For free or low-cost legal help, see the USAGov legal aid page.

Frequently asked questions

Is a denial on my Medicare Summary Notice final?

Not necessarily. The MSN explains how to ask for a redetermination, which is the first level of appeal. Each later level has its own deadline.

What if my services are ending too soon?

Medicare says you have the right to a fast appeal if you think covered services from a hospital, skilled nursing facility, home health agency, or hospice are ending too soon. Your provider should give you a written notice explaining how. If you did not get one, ask for it.

Does signing an ABN mean Medicare denied my claim?

No. An ABN is the provider's advance warning that Medicare may not pay. Medicare decides the claim later.

Can a family member handle my appeal?

Yes. Medicare allows you to appoint a representative. Follow the instructions on Medicare's site to make the appointment official.

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General information, not legal advice. Laws change and every case is different — talk to a licensed attorney about your situation.