What to Do If You Obtain a Formal Medicare Denial

By Patricia Barry

Copyright © 2015 AARP

If you’re in the traditional Medicare program, you may obtain a denial of coverage for a medical service or piece of equipment in one of two ways:

  • Checking your Medicare Summary Notice (MSN): This document is the statement that Medicare sends you every three months as a record of the services you’ve received during that time. If you see a service or item that Medicare has denied payment for, this denial means the determination has already been made. To appeal that decision, you must file within 120 days, following the detailed instructions on the notice.

  • Checking the first option on an Advance Beneficiary Notice of Non-Coverage (ABN): You may be given this notice by any providers (doctors, hospitals, skilled nursing facilities, medical equipment suppliers, and so on) if they believe that Medicare won’t cover the service or item you’ve asked for. By checking the first option on that notice, you’re essentially asking for a determination on whether Medicare will pay.

In either case, the determination is made by the administrative contractor that Medicare uses in your region to decide claims. If you want to challenge a denial, you can proceed to level 1 of the appeals process, which I describe later in this chapter.

If you’re in a Medicare Advantage plan the process is different. These plans don’t use Medicare Summary Notices. Instead, they send regular Explanation of Benefits notices to itemize the medical services their members have received. Nor do they issue ABNs, because they must explain their coverage policies in the Evidence of Coverage documents they send to enrollees each year.

Nonetheless, if you think your plan should provide, pay for, or continue to pay for a service or an item, you have the right to request it. The plan must respond within 14 days or, if your doctor says a faster decision is needed for the sake of your health, within 72 hours. If the plan turns down your request, the notice it sends you counts as a denial of coverage that you can challenge through the appeals process. The notice explains how to appeal the decision.