What Should I Do If Medicare Denies a Claim?
Short answer
Start with the denial notice or Medicare Summary Notice, identify the exact reason, gather supporting records and follow the appeal instructions by the stated deadline if you disagree.
Coverage
Original Medicare claim appeals generally begin with a redetermination. Medicare Advantage and Part D use plan-specific organization-determination or coverage-determination appeal processes.
Not Automatic
Do not assume every denied claim is a final coverage decision. Some problems are billing or documentation errors that can be corrected, while others require a formal appeal.
Costs And Ma
Urgent health situations may qualify for expedited review under applicable rules.
Practical Example
If a claim was denied because the provider omitted required documentation, first determine whether corrected billing can resolve it; if not, use the appeal pathway on the notice.
Questions to verify
- Why was the claim denied?
- Can the provider correct a billing error?
- What is the appeal deadline?