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How to appeal when Medicare refuses a claim

Dear Toni: I have a $2,000 doctor bill with a new cardiologist, and Medicare says it will not pay. I recently retired and enrolled in Medicare and a Medicare supplement for the freedom to pick my own doctor!

This is too confusing for me. I need some advice. — Joey, Cleveland

Dear Joey: I rarely see a problem with doctor’s/provider’s bills, but when it does happen, there is a process you must follow to find out if the office visit or procedure will be paid as a “Medicare-approved” service.

If original Medicare will not pay for care you received, you can find this out by visiting medicare.gov and opening a Medicare.gov account to view your Medicare information and medical claims. Those not able to open a Medicare.gov account can wait until they receive a Medicare summary notice.

These notices are mailed four times a year and contain information about submitted charges, the amount that Medicare paid and the amount you are responsible for. They are used only with original Medicare and not with Medicare Advantage or Medicare Part D prescription drug plans.

Here’s what you should do if you think the claim is medically necessary:

1. Find out if there was a billing mistake. Medicare uses a set of service codes for processing medical claims. Each medical service has been assigned a specific code. Sometimes providers accidentally use the wrong codes when filling out paperwork, and this can result in Medicare denials. A denial can sometimes be easily resolved by asking your doctor to double-check that your claim was submitted with the correct code.

2. If the medical provider believes the claim was correctly coded or is unwilling to refile the claim, your next step is to appeal. Your Medicare summary notice will have instructions on how to appeal. Write “Please Review” on the bottom and sign the back. Make a copy for your files. Then mail the signed original to Medicare.

3. If possible, get a letter from your health care provider stating that the service was necessary and why. Send this with your Medicare summary notice.

4. If you need help filing your appeal, call Medicare at 800-633-4227.

5. Send your appeal certified mail with return receipt if using the post office, or ask for a signed delivery confirmation if using another delivery service.

6. Keep photocopies and records of all communication with Medicare, whether written or oral, concerning your denial.

Toni King is an author and columnist on Medicare and health insurance issues. If you have a Medicare question, email info@tonisays.com or call 832-519-8664.

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