- Medicare denial letters notify you of services that won’t be covered for a variety of reasons.
- There are several different types of letters, depending on the reason for denial.
- Denial letters should include information about how to appeal the decision.
You will receive a Medicare denial letter when Medicare denies coverage for a service or item or if a specific item is no longer covered. You’ll also receive a denial letter if you are currently receiving care and have exhausted your benefits.
After you receive a denial letter, you have the right to appeal Medicare’s decision. The appeals process varies depending on which part of your Medicare coverage was denied.
Let’s take a closer look at the reasons you might receive a denial letter and the steps you can take from there.
Medicare may issue denial letters for various reasons. Example of these reasons include:
- You received services that your plan doesn’t consider medically necessary.
- You have a Medicare Advantage (Part C) plan, and you went outside the provider network to receive care.
- Your prescription drug plan’s formulary does not include a drug that your doctor prescribed.
- You have reached your limit for the number of days you may receive care in a skilled nursing facility.
When you receive a Medicare denial letter, it usually includes specific information on how to appeal the decision. We’ll go over the details of the appeals process later in this article.
Medicare may send you a few different types of denial letters. Here, we’ll discuss a few common types of letters you might receive.
Generic notice or Notice of Medicare Non-Coverage
You’ll receive a Notice of Medicare Non-Coverage if Medicare stops covering care that you get from an outpatient rehabilitation facility, home health agency, or skilled nursing facility. Sometimes, Medicare may notify a medical provider who then contacts you. You must be notified at least 2 calendar days before services end.
Skilled Nursing Facility Advanced Beneficiary Notice
This letter will notify you about an upcoming service or item at a skilled nursing facility that Medicare will not cover. In this case, Medicare has deemed the service not medically reasonable and necessary. The service might also be deemed custodial (not medical related), which is not covered.
You may also receive this notice if you’re close to meeting or exceeding your allowed days under Medicare Part A.
Fee-for-Service Advance Beneficiary Notice
This notice is given when Medicare has denied services under Part B. Examples of possible denied services and items include some types of therapy, medical supplies, and laboratory tests that are not deemed medically necessary.
Notice of Denial of Medical Coverage (Integrated Denial Notice)
This notice is for Medicare Advantage and Medicaid beneficiaries, which is why it’s called an Integrated Denial Notice. It may deny coverage in whole or in part or notify you that Medicare is discontinuing or reducing a previously authorized treatment course.
If any part of your denial letter is ever unclear to you, you can call Medicare at 1-800-MEDICARE or contact your insurance company for more information.
If you feel that Medicare made an error in denying coverage, you have the right to appeal the decision. Examples of when you might wish to appeal include a denied claim for a service, prescription drug, test, or procedure that you believe was medically necessary.
How you file an appeal often depends on which Medicare part the claim falls under. Here’s a quick guide on when and how to submit a claim:
|Part of Medicare||Timing||Appeal form||Next step if first appeal is denied|
|A (hospital insurance)||120 days from initial notification||Medicare Redetermination Form or call 800-MEDICARE||proceed to level 2 reconsideration|
|B (medical insurance)||120 days from initial notification||Medicare Redetermination Form or call 800-MEDICARE||proceed to level 2 reconsideration|
|C (Advantage plans)||60 days from initial notification||your Medicare Advantage plan must notify you of its appeals process; you can also apply for an expedited review if you need an answer faster than 30–60 days||forward to level 2 appeals; level 3 appeals and higher are handled via the Office of Medicare Hearings and Appeals|
|D (prescription drug insurance)||60 days from initial coverage determination||you can request a special exception from your drug plan or request redetermination (appeals level 1) from your plan||request further reconsideration from an Independent Review Entity|
If you have Medicare Part C and are dissatisfied with how your plan treated you during the appeals process, you can file a grievance (complaint) with your State Health Insurance Assistance Program.
Read your plan’s appeals process carefully. Your denial letter will usually include information or even a form you can use to file an appeal. Fill out the form completely, including your telephone number, and sign your name.
Ask your healthcare provider to help with your appeal. Your provider can supply a statement about why the procedure, test, item, treatment, or medication in question is medically necessary. A medical equipment supplier may be able to send a similar letter when necessary.
After you receive your Medicare denial letter and decide to appeal it, your appeal will usually go through five steps. These include:
- Level 1: redetermination (appeal) from your plan
- Level 2: review by an Independent Review Entity
- Level 3: review by the Office of Medicare Hearings and Appeals
- Level 4: review by the Medicare Appeals Council
- Level 5: judicial review by a federal district court (usually must be a claim that exceeds a minimum dollar amount, which is $1,670 for 2020)
It’s very important to carefully read and understand your denial letter in order to avoid further denials in the appeals process. You can also take other actions to help you accomplish this:
- Reread your plan rules to ensure you are properly following them.
- Gather as much support as you can from providers or other key medical personnel to back up your claim.
- Fill out each form as carefully and exactly as possible. If necessary, ask another person to help you with your claim.
In the future, you can avoid denial of coverage by requesting a preauthorization from your insurance company or Medicare.
- You may receive a Medicare denial letter if you do not follow a plan’s rules or if your benefits have run out.
- A denial letter will usually include information on how to appeal a decision.
- Appealing the decision as quickly as possible and with as many supporting details as possible can help overturn the decision.