How to Appeal a Medicare Claim Rejection

It's not uncommon for original Medicare claims to be denied for a variety of reasons. For instance, a Medicare claim might be denied if the service is covered by other insurance, if you do not meet the criteria for the medical service or if you are not enrolled in Part B coverage. Occasionally Medicare will incorrectly deny a claim because it does not have the right or proper information, in which case it's possible to appeal the denial.

Things You'll Need

• Copy of your medical bill
• Copy of your Medicare coverage

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Instructions

How to Appeal a Medicare Claim Rejection

• 1

  Verify your insurance coverage. Make sure you do not have another insurance payer, such as Cobra or another private health care provider. Review your Medicare coverage to determine if you have original Medicare or an expanded Medicare health plan. Check your paperwork for the dates of coverage, the type of coverage and any limitations on services or products purchased.

• 2

  Review your Medicare Summary Notice for the denied claim. Notices include a reason for the denial if the claim was denied. Compare this reason to your insurance coverage to verify that the service or item purchased does not breech limitations for your policy. This will help you determine whether or not the denied claim deserves an appeal.

• 3

  Read the instructions on the back of your Medicare Summary Notice for filing an appeal and obtain a Medicare Redetermination Request form (Form CMS20027). Request the form at your local Medicare office or by contacting Medicare to have the form mailed directly to your home at no cost. You can also download and print it from Medicare's website.

• 4

  Complete the Medicare Redetermination Request form by supplying your name and Medicare account number along with information about the denied claim. Provide a detailed explanation of why you disagree with the claim's denial. Cite references to your policy and coverage as support for your appeal. Complete the form by filling in additional information for Medicare to consider, along with your personal information.

• 5

  Sign the form and make a copy for your records. Mail or fax the original signed form to the address or fax number as instructed on your Medicare Summary Notice within 120 days of the notice of denial or the statute of limitations for an appeal will expire. Follow up on your appeal by calling 1-800-MEDICARE within six weeks if you have not received a decision. You can appeal the claim denial two more times if your first appeal is denied.