As most know, Medicare is one of the elderly health services provided by the federal government. It is a health insurance program for people age 65 and older (or younger individuals with certain disabilities) that helps individuals cover medical fees, such as hospital stays and other medical procedures.

This federal plan can be very beneficial for individuals in need of extra funding to pay for their healthcare and it can even work with other types of insurance, so you receive multiple sources of coverage. 

But what happens when you are denied Medicare? 

What are the steps you can take for an appeal? 

You can find all those answers here, as we at Golden Guardian work to educate you on all your healthcare needs. Follow these steps if you or a loved one is denied Medicare.

Find Out Why You Were Denied 

When Medicare denies payment of a claim, they send out a notice quarterly called the Medicare Summary Notice (MSN). The reason for the denial will be written in this notice. In most cases, when a claim is denied it’s because it wasn’t billed properly, which can result in a coding error, or there was an issue with the claim form. These problems can be easily corrected without the need of filing an appeal. 

If this has happened to you, go to the next step to see what you can do. Other times, individuals are denied because Medicare found the service or procedure unreasonable or unnecessary. If this is the case, you may need to file an appeal.

Contact the Hospital or Medicare

If you were denied because the claim was billed incorrectly or there was another error, such as missing information, then first contact your doctor to prove to Medicare that the service was needed. You may also need to contact Medicare to have any mistake on their end corrected and the claim resubmitted.

How to Appeal 

If you need to appeal the denial, you can find information to do so on the back of the Medicare Summary Notice. You need to follow the instructions very carefully and submit the appeal within the allotted timeframe. You will have 120 days after receiving the MSN to request a redetermination. If you have any information that supports why a treatment or doctor’s visit was necessary and reasonable, such as a doctor’s letter of explanation, make sure to submit that information. If you documented phone calls or conversations with the doctor, hospital staff, or Medicare that is in your favor, use this to strengthen your case.

In general, decisions are made 60 days after the Medicare claims reviewer receives your appeal.

If your appeal is denied, you have an additional 180 days to request a reconsideration. You will need to submit additional information to support why the medical service was necessary or reasonable. If it is denied a third time, you must pay a minimum fee of $150 to have a hearing with a judge of administrative law. You can take the appeal as far as requesting a judicial review in the U.S. District Court, but you must pay additional fees. 

Elderly Health Services Medicare Won’t Cover 

There are some services that Medicare won’t cover. Knowing what types of services are not covered will help you avoid problems in the future. The following are elderly health services that Medicare does not cover:

• Dental exams and most dental care
• Routine eye exams
• Hearing exams and other hearing services
• Custodial care
• Long-term care
• Alternative treatments
• Most chiropractic care
• Routine foot care
• Most overseas care
• Outpatient prescription drugs

You will have to pay for these elderly health services out of pocket or with a different insurance plan. If you have Medicare Advantage, you may be able to pay for some of the services that Original Medicare does not cover, such as outpatient prescription drugs.

Contact Golden Guardians 

If you or a loved one needs assistance with denied claims and other elderly health services, contact our Medicare Advocacy Service. We specialize in educating Medicare beneficiaries and advocating for their healthcare needs. We can educate you on the benefits available in your current health plan, and where to find additional services such as:

• Medicaid
• Diabetic supplies
• Transportation

Learn more about our services and contact us if you have any questions.