How to Appeal a Denied Medicare Claim for Your Loved One

Learn the step-by-step process to successfully appeal a Medicare claim denial and get the coverage your family member deserves.

1. Understand Why the Claim Was Denied. Start by carefully reading the Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) that shows the denial. Look for the specific reason code and explanation. Common reasons include services deemed not medically necessary, incorrect billing codes, or missing documentation. Keep this paperwork handy as you'll need to reference it throughout the appeal process. If the reason isn't clear, call Medicare at 1-800-MEDICARE to ask for clarification.
2. Gather Your Documentation. Collect all relevant medical records, doctor's notes, test results, and any other documentation that supports why the service or treatment was necessary. Contact your loved one's healthcare provider to request copies of medical records that show the medical necessity for the denied service. Also gather the original claim forms, any prior authorizations, and correspondence with Medicare. Having complete documentation is crucial for a successful appeal.
3. File Your First-Level Appeal (Redetermination). You have 120 days from the date on your MSN to file your first appeal, called a redetermination. Write a clear letter explaining why you believe the denial was wrong, referencing the medical documentation you've gathered. Include copies (never originals) of all supporting documents. Mail or fax your appeal to the Medicare contractor listed on your MSN. Keep copies of everything you send and use certified mail to prove delivery. You'll typically get a decision within 60 days.
4. Proceed to Higher Appeal Levels if Needed. If your redetermination is denied, you can request a reconsideration by a Qualified Independent Contractor within 180 days. If that's also denied, you can request a hearing before an Administrative Law Judge if the amount in question is at least $180. For higher amounts, you can eventually appeal to federal court. Each level has specific time limits and procedures, so act quickly if you want to continue the process.
5. Consider Getting Professional Help. If the appeal process feels overwhelming or involves a large amount of money, consider getting help from a Medicare advocate, social worker, or attorney who specializes in Medicare issues. Your State Health Insurance Assistance Program (SHIP) offers free counseling and can help with appeals. Some healthcare providers also have patient advocates who can assist with the paperwork and process.