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Reasons for Medicare to Deny Claims

Medicare is a government-run health insurance program that provides insurance coverage to people that are age 65 or older. Certain people under the age of 65, such as those with disabilities or those suffering from permanent kidney failure may also be eligible for Medicare. The government's official Medicare site says that you should only need to file Medicare claims in rare cases since doctors and suppliers are required to file claims for services and supplies. Medicare may deny claims made for many different reasons.

  1. Not Eligible for Coverage

    • Medicare will deny claims that you make if you are not eligible for Medicare coverage. For example, if you were eligible for Medicare due to a disability that you subsequently overcame, you might no longer be eligible for coverage. Medicare is a subsidized insurance program, but people covered by Medicare may be required to pay insurance premiums, deductibles and coinsurance toward certain types of coverage. If you fail to pay Medicare premiums you may not be eligible for coverage.

    Care not Covered by Medicare

    • Medicare can help pay for many common medical costs, but not all health costs will necessarily be covered by Medicare. The official government site for Medicare states that the following are examples of types of care that are not covered by Medicare part A or B: acupuncture, cosmetic surgery, hearing aids, orthopedic shoes, dental care and custodial care. In addition, if you receive care from a health care facility that is not a Medicare provider, you may not be eligible for compensation from Medicare. Claims must be made within a year of receiving care, so if you wait too long to make a claim it may be denied.

    Other Reasons for Denials

    • There are a host of other reasons why Medicare could deny your claim. The Centers for Medicare & Medicaid Services states that claim adjustment codes are used to designate why claims are adjusted or denied and that current codes can be viewed at the "Washington Publishing Company: Claim Adjustment Reason Codes" site (see Resources).

    Considerations

    • If a Medicare claim is denied and you think you should receive compensation from Medicare you can file an appeal. The official Medicare website says that you can also file an appeal if Medicare stops covering all or part of a service that you think you still need and provides information about how to file appeals and grievances based on your Medicare coverage type (see Resources.).

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