My Medicare claim was denied: how do I appeal?

My Medicare claim was denied. What do I do first?

Take a breath. A denial is a decision you are allowed to challenge. The first job is to find out which kind of Medicare you have, because the appeal path is different.

If you have Original Medicare, look for your Medicare Summary Notice (MSN). If you have a Medicare Advantage plan, look for the denial notice from your plan. Either letter tells you how to start an appeal and gives you a date to watch.

What is the difference between Original Medicare and Medicare Advantage when I appeal?

Original Medicare is the government program. Your claims go to Medicare, and a Medicare Administrative Contractor (MAC) makes the first appeal decision.

A Medicare Advantage plan is run by a private insurance company that contracts with Medicare. For the first appeal, the plan itself reviews its own denial. Medicare says the appeals process varies based on the kind of coverage you have, so check which card is in your wallet.

What is a Medicare Summary Notice and where do I find my denial?

The Medicare Summary Notice, or MSN, is a notice mailed to people with Original Medicare. Medicare says it is not a bill. It lists the services providers billed to Medicare, what Medicare paid, and the maximum amount you may owe the provider.

You get one every 6 months if you had services in that period, or you can choose electronic notices. If something is denied, the last page of the MSN has step-by-step appeal instructions. It also helps to call the provider's office first to make sure they sent the correct information, since they may be able to fix and resubmit a mistake.

How do I file the first appeal for Original Medicare?

The first level is called a redetermination. Here is the short version.

The MAC generally decides within 60 days after it gets your appeal. If someone is helping you as your representative, include a copy of the Appointment of Representative form.

• Step 1: Read your MSN. Find the denied item, the date on the notice, and the appeal deadline printed on it.
• Step 2: Gather your details. Write down your name, address, Medicare Number, the specific items or services, and the dates you are appealing.
• Step 3: Explain and attach support. Say why you believe it should be covered, and attach supporting information such as a doctor's note.
• Step 4: Send it before the date on your MSN. Use the Redetermination Request Form (CMS-20027), the instructions on your MSN, or a written request to the MAC. Keep a copy.

What is the deadline to appeal a Medicare denial?

It depends on which kind of Medicare you have. For Original Medicare, Medicare says you must file your first appeal by the date in your MSN. If you miss it, you may still appeal if you can show good cause, such as an illness, disability, or accident that delayed you.

For a Medicare Advantage plan, the first appeal must be filed within 65 days from the date on the plan's initial denial notice. If you file late, you must give a reason. When in doubt, file early and ask for help afterward.

What if my health is at risk while I wait?

If you have a Medicare Advantage plan and waiting for a standard decision could seriously jeopardize your life, health, or ability to regain maximum function, you can ask for a fast appeal. Medicare says that when the plan decides this is the case, or your doctor tells the plan it is, the plan must give its decision within 72 hours. A standard appeal for care you have not received yet allows 30 days, and a payment appeal allows 60 days. These times can be extended by up to 14 days in some cases.

If your coverage is a health insurance plan that is not Medicare, HealthCare.gov says you can ask your insurer for a full and fair review, and if the case is urgent, the insurer must speed up the process. The exact rules depend on the kind of plan you have, so check your plan's denial notice.

What if I lose the first appeal?

You can usually go to the next level. In Original Medicare, the second level is a reconsideration by a Qualified Independent Contractor, and you have 180 days after you get the MAC's decision letter to ask for it. Levels 3, 4, and 5 each have 60-day windows.

In a Medicare Advantage plan, if the plan decides against you in full or in part, your appeal is sent to level 2, an Independent Review Entity, automatically. Each decision letter explains how to move up.

Your checklist

• Find the denial letter or Medicare Summary Notice
• Circle the date on the notice and the appeal deadline
• Write down your Medicare Number and the denied service and date
• Ask your doctor for a short supporting note
• Send your appeal before the deadline and keep a copy
• Write down who you talked to, the date, and what they said
• Mark the decision date on your calendar for the next step

A letter you can copy

[Date] To: [Medicare Administrative Contractor name and address, from your Medicare Summary Notice] Re: Request for redetermination (first-level appeal) Name: [Your full name] Address: [Your address] Medicare Number: [Your Medicare Number] Claim or notice date: [Date on your Medicare Summary Notice] I am appealing the denial of the following service: [Service or item] on [Date of service], provided by [Provider name]. I believe this should be covered because: [Explain in a few sentences, in your own words]. I have attached: [Doctor's note, bills, or other support]. Please send your decision to the address above. Sincerely, [Your signature and printed name] [Phone number]

Which rules apply to you?

The steps and deadlines on this page can differ by the kind of plan you have. Your own denial letter always comes first.

• Coverage through a job:ask your HR team whether the plan is “self-funded” or “fully insured.” It can change who you can ask for help. Most private-sector job plans fall under a federal law called ERISA, and the U.S. Department of Labor’s EBSA takes health plan questions at Ask EBSA or 1-866-444-3272.
• Marketplace plan: follow the appeal steps at HealthCare.gov.
• Medicare or Medicaid: each has its own appeal process, listed on your notice.
• Dental-only plan: your plan contract sets the appeal rights, so read it and your letter.

Related answers

• Medicaid denied my care: how do I ask for a fair hearing?
• How to read an insurance denial letter
• How to write an insurance appeal letter
• Internal appeal vs external review: what is the difference?
• All answers

Free tools for the next step

Keep your appeal papers in one place. Take a photo of your denial letter, EOBs and insurance cards with GetPreCare, so they are on your phone when the insurer or the office asks. Free. Open GetPreCare. Helping a parent or partner? Set it up for them.