How to appeal a denied Medicare claim

Dear Savvy Senior: What steps do I need to take to appeal a denied Medicare claim? — Frustrated Retiree

Dear Frustrated Retiree: If you disagree with a coverage or payment decision made by Medicare, you can appeal, and you’ll be happy to know that many appeals are successful.

But before going that route, talk with the doctor, hospital and Medicare to see if you can spot the problem and resubmit the claim. Many denials are caused by simple billing code errors by the doctor’s office or hospital. If that doesn’t fix the problem, here’s how to appeal.

Original Medicare appeals

If you have original Medicare, start with your quarterly Medicare Summary Notice. This statement will list all the services, supplies and equipment billed to Medicare for your medical treatment and will tell you why a claim was denied. You can also check your Medicare claims early at MyMedicare.gov or by calling 800-633-4227.

There are five levels of appeals for original Medicare, although you can initiate a “fast appeal” if you’re getting services from a hospital, skilled nursing facility, home health agency, outpatient rehabilitation facility or hospice, and the service is ending.

You have 120 days after receiving the summary notice to request a “redetermination” by a Medicare contractor, who reviews the claim. Circle the items you’re disputing on the notice, provide a written explanation of why you believe the denial should be reversed and include any supporting documents. Then send it to the address on the form.

You can also download the Medicare redetermination form at CMS.gov or call 800-633-4227 to request a copy by mail.

The contractor will usually decide within 60 days after receiving your request. If your request is denied, you can request reconsideration from a different claims reviewer and submit additional evidence.

A denial at this level ends the matter, unless the charges in dispute are at least $190 (the threshold for 2025). In that case, you can request a hearing with an administrative law judge. The hearing is usually held by videoconference or teleconference.

If you have to go to the next level, you can appeal to the Medicare Appeals Council. Then, for claims of at least $1,900 (the threshold for 2025), the final level of appeals is judicial review in U.S. District Court.

Advantage and Part D appeals

If you’re enrolled in a Medicare Advantage health plan or Part D prescription drug plan, the appeals process is slightly different. With these plans you have only 65 days to initiate an appeal. In both cases, you must start by appealing directly to the private insurance plan, rather than to Medicare.

If you think that your plan’s refusal is jeopardizing your health, you can ask for an expedited appeal, in which a Part D insurer must respond within 24 hours, and Medicare Advantage plan must provide an answer within 72 hours.

If you disagree with your plan’s decision, you can file an appeal, which like original Medicare, has five levels. If you disagree with a decision made at any level, you can appeal to the next level.

For more information, along with step-by-step procedures on how to appeal to Medicare, go to Medicare.gov/claims-appeals.

Also, make sure to keep photocopies and records of all communication with Medicare, whether written or oral, concerning your denial.

Send your senior questions to: Savvy Senior, P.O. Box 5443, Norman, OK 73070, or visit SavvySenior.org.