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How to Dispute a Denial of a Medicare Claim

Medicare is a national health insurance program operated by the Centers for Medicaid and Medicare Services, a division of the United States federal government that operates under the auspices of the Social Security Administration. The program is separated into sections A and D, and applicants must have been a permanent resident of the United States for at least five years to be eligible for either. For parts A and B, you must be at least 65 years old and eligible for Social Security benefits. You may also qualify if you are under the age of 65 but are chronically incapacitated and have been receiving disability benefits for at least two years, or if you have end-stage renal disease.

Part C, often known as Medicare advantage, is obtained through private insurers, although one must already be enrolled in Part A or B to qualify. Part D, which is also available through private insurers, covers prescription medications and is also available to members of parts A and B.

 

How to Appeal a Denied Application

Determine the Appropriateness of an Appeal

If you’ve already applied for Medicare and are receiving benefits but have been denied coverage for a medical bill, you may want to consider filing an appeal. Appeals are measures done in response to a dispute with a Medicare coverage or payment decision. You have the right to appeal to any of Medicare’s four components if:

  • It denies your request for a health care service, supply, or medication that you believe you are entitled to.
  • The amount you should pay for health care services, prescription medications, supplies, or other products is refused, OR
  • Payment is denied for a health care service, item, supply, or prescription medication that you already own.

Evaluate the Medical Summary Notice you have received.

Appealing begins with an examination of the Medical Summary Notice (MSN) that is mailed to you every three months. It summarizes all services and materials invoiced to Medicare by providers throughout a quarter. You can ascertain the amount paid by Medicare and what is refused using the MSN. It is typically a preliminary assessment made by the company that handles Medicare billing.

Objecting to the Decision

The initial judgment may be appealed in one of the following ways:

  • Completing a Redetermination Request Form and submitting it to the contractor assigned to your case on the MSN
  • Adhere to the appeals guidelines as specified on the MSN. You may choose to consult your physician or healthcare professional regarding any information that may be pertinent to your situation.
  • Making a written request to the organization that processes Medicare claims (the contact information for this organization can be found on the MSN under the Appeals Information section. The petition must state why you disagree with the original finding and the specifics you require to be determined in advance.

On a signed form, you must enter your name, address, phone number, and Medicare number. All documentation presented in support of the appeal must include the Medicare number. After the initial redetermination request is filed, more information or supporting evidence may be submitted.

What Can I Expect Following an Appeal?

UnitedHealthcare evaluates all appeals received before to the expiration of sixty calendar days from the date of receipt of the MSN. Claims are processed in around 30 days. However, if further information is submitted following the original appeal, an additional 14 days may be required. In time-sensitive situations, one may request an accelerated decision. When the regular timescale for decision-making might threaten your health, the expedited method is implemented. These determinations are made within 72 hours.