If your Part A or Part B Medicare claim is denied - for people in Original fee-for-service Medicare
You have the right to appeal any decision about your Medicare services. If Medicare does not pay for an item or service, or if you are not provided an item or service you think you should receive, you can appeal.
Ask your doctor or provider for a letter to support your appeal, or for medical records related to the bill that might help your case. Your appeal rights are described on the back of the Explanation of Medicare Benefits (EOMB) or Medicare Summary Notice (MSN) form.
Note: An appeal is a special kind of procedure you follow if you disagree with a decision about your health care. It is a way to deal with a complaint about a treatment decision or service not covered. A grievance, however, is different. A grievance is a complaint about the way your Medicare health plan is providing care.
For example, you may file a grievance if you have problems with cleanliness of the facility, reaching the plan’s customer service department, staff behavior, and/or operating hours.
If a Part A or Part B claim is denied or not handled in the way you think it should be, you can challenge the decision. It pays to ask for a formal Redetermination or Reconsideration of the initial decision. Very few people do this, but when they do — more than half the claims challenged result in paid claims or higher payments.
The sections below explain the steps for coverage and payment appeals, expedited appeals and how to file quality of care complaints.
To learn more:
Coverage and payment appeals
Expedited appeals for termination of services
Quality of health care complaints
Page updated October 13, 2008
