How to Appeal a Denied Medicare Claim

A denied Medicare claim can be overwhelming, but understanding the reason behind the denial and knowing how to navigate the appeals process can make all the difference.

From coding errors to disputes over medical necessity, this guide simplifies the appeals process so you can take action and secure the coverage you need.

1. What Are the First Steps to Take When Appealing a Medicare Denial?

Once you know why your claim was denied, it’s time to start the appeal process. Begin by organizing your documentation and understanding each required step.

• Documents to Collect:
  • Explanation of Benefits (EOB): Outlines the denial and what Medicare covered (this could include medical necessity issues, documentation errors, or billing code mistakes).
  • Doctor’s Notes: Supporting statements explaining the medical necessity of the treatment.
  • Medical Records: Any relevant records that support your claim and provide context for the appeal.

Organizing these documents can help you create a strong appeal. The more complete and detailed your paperwork, the higher your chances of approval.

Let advocates handle the paperwork. Get yours today.

2. Why Was My Medicare Claim Denied?

Facing a denied Medicare claim can feel overwhelming, especially when you rely on coverage for important medical care. Understanding the denial reason is crucial, as it will guide the direction of your appeal.

• Common Medicare Denial Reasons:
  • Medical Necessity: Medicare didn’t deem the treatment necessary.
  • Documentation Errors: Missing, incomplete, or misfiled information.
  • Coding Mistakes: Errors in billing codes lead to claim rejections.

Get an expert to appeal your claim for you.

The next step will be to file a redetermination request.

3. What’s Involved in Filing a Medicare Redetermination Request?

A "redetermination request” is the first level of a Medicare appeal. It is a formal review where Medicare reexamines the original decision. It gives you a chance to present additional evidence—such as medical records or documentation—to support your case.

There are two ways you can request a redetermination.

1. Fill out the form CMS-20027 (download here).
2. Make a written request containing all of the following information:
   • Beneficiary name
   • Medicare number
   • Specific service(s) and/or item(s) for which a redetermination is being requested
   • Specific date(s) of service
   • Name of the party, or the representative of the party
   • An explanation of why the appellant disagrees with the contractor's determination

This letter should clearly detail why the treatment is medically necessary and include all relevant evidence.

• Tips for a Successful Redetermination:
  • Explain Medical Necessity: Clearly outline why the treatment is essential for your health.
  • Include Supporting Evidence: Attach all relevant documents to build a strong case.
  • Meet Filing Deadlines: Medicare appeals are time-sensitive, so submit your request by the deadline specified on your EOB.
  • Return Receipt For Mail: When mailing your claim, submit certified mail with a return receipt requested to ensure it has been received.

If structuring this request feels challenging, Solace advocates have experience creating effective, well-documented appeals for patients.

4. How Can I Appeal Medicare’s Decision if My First Request Is Denied?

If Medicare denies your redetermination request, additional appeal levels are available. The next step involves a reconsideration by a Qualified Independent Contractor (QIC), followed by higher levels of appeal like the Administrative Law Judge (ALJ) hearing, Medicare Appeals Council review, and federal court review.

• When to Escalate: If strong supporting evidence still doesn’t result in approval, it may be time to escalate to higher appeal levels.
  1. Medicare Appeals Council Review: If the ALJ denies your appeal, the Council provides a higher level of review.
  2. Federal Court Review: The final step for unresolved appeals, where the case is taken to federal court (also requiring a minimum claim amount).
• Consider Professional Support: Each level becomes more complex, so having a knowledgeable advocate can greatly improve your chances of success.

5. Why Work with an Advocate for Medicare Appeals?

Appealing a Medicare claim can be time-intensive and complicated. Solace’s advocates are trained to handle every step of the appeal, providing:

• Expert Knowledge of Medicare: Advocates understand Medicare claims and appeals inside out, so you don’t have to.
• Full-Service Support: From gathering documents to filing redeterminations and representing your case, advocates are with you each step of the way.
• Reduced Stress and Higher Success Rates: They take the stress out of appeals, allowing you to focus on your health while they work to get your claim approved.

Need help appealing your claim? Find a Solace advocate.

FAQ: Common Questions About Medicare Appeals

What is a Medicare redetermination request?

A redetermination request is the first step in appealing a denied Medicare claim. It involves submitting supporting documents and a detailed explanation of why you believe the denial was incorrect.

How long do I have to appeal a Medicare claim denial?

Medicare appeal deadlines vary, but typically, you have 120 days from the date on the Explanation of Benefits to submit a redetermination request. Always check your EOB for specific deadlines.

What types of documentation are needed for a Medicare appeal?

Common documents include your Explanation of Benefits, medical records, doctor’s notes on medical necessity, and itemized bills.

Can a Medicare appeal be denied more than once?

Yes, if the initial redetermination is denied, you can move to additional appeal levels, each with increasingly rigorous review.

How can Solace help with my Medicare appeal?

With extensive experience in Medicare appeals, Solace Advocates work tirelessly to improve your chances of approval. Solace advocates can manage every aspect of the appeal process, from gathering documents to representing you at each appeal level.