Medicare Coverage Denials and Appeals: What To Do When a Claim Is Refused

Medicare coverage can feel complicated even when everything goes smoothly. When a claim is denied or a service is not covered the way you expected, it can be confusing and stressful. Understanding why Medicare denied coverage and how the appeals process works can help you decide what to do next.

This guide from HowToGetAssistance.org is informational only. It is not an official government site, and you cannot apply for, appeal, or manage Medicare benefits through this website. Instead, this article explains typical processes and points you toward official Medicare channels you can use.

Understanding Medicare Coverage Denials

A coverage denial generally means Medicare or your Medicare plan has decided not to pay for a service, item, or prescription the way it was billed.

Common types of denials include:

• Service not covered at all by Medicare
• Service not medically necessary according to Medicare rules
• Wrong billing or coding by the provider
• Out-of-network provider (for some Medicare Advantage plans)
• Prior authorization missing or denied
• Quantity limits exceeded (often for drugs)
• Deadline or filing rules not met

Medicare denials usually appear in writing as:

• An Explanation of Benefits (EOB) from your plan
• A Medicare Summary Notice (MSN) (for Original Medicare)
• A denial letter from your Medicare Advantage or Part D plan

👉 First step: Carefully read the denial notice. Look for:

• What was denied
• The reason code or explanation
• The date of the decision
• How and when you can appeal
• Where to send an appeal or which phone number to call

Original Medicare vs. Medicare Advantage vs. Part D: Why It Matters

Your appeal options depend on the type of Medicare coverage you have:

Original Medicare (Part A and/or Part B)

• Managed directly by the federal Medicare program
• You typically receive a Medicare Summary Notice (MSN)
• Appeals go through Medicare’s standard 5-level appeals process

Medicare Advantage (Part C)

• Coverage provided through a private insurance company approved by Medicare
• You receive plan-specific EOBs and letters
• Appeals often start by following instructions from your plan, then may move into Medicare’s higher appeal levels

Medicare Prescription Drug Plans (Part D)

• Also offered through private plans
• Denials may involve:
  • Non-formulary drugs
  • Prior authorization requirements
  • Step therapy
  • Quantity limits
• You may need to request a coverage determination or exception first, then appeal if denied

If you are unsure which type of plan you have, check:

• Your Medicare card
• Any plan ID card from an insurance company
• Notices from your plan or from Medicare
• Information from your Social Security office or the official Medicare helpline

Step 1: Confirm What Was Denied and Why

Before you file a Medicare appeal, it helps to be clear about the issue.

How to review the denial

1. Locate the document

   • Original Medicare: Look for the Medicare Summary Notice (MSN)
   • Medicare Advantage / Part D: Look for an EOB or denial letter from your plan

2. Check the service or item

   • Date of service
   • Name of provider or facility
   • Drug name and dosage (for Part D)

3. Find the denial reason

   • Phrases like “not medically necessary,” “not a covered benefit,” “prior authorization not obtained,” or “submitted too late”

4. Look for timelines

   • Most appeals have a strict deadline, often 60 days from the date on the notice
   • Some situations allow for expedited (fast) appeals

If you cannot understand the denial:

• Call the number on your Medicare card or your plan’s member services number
• Ask your doctor’s billing office to explain the reason code
• Contact your State Health Insurance Assistance Program (SHIP) for free, local counseling

Step 2: Decide Whether to Appeal or Request a Correction

Not every problem requires a full appeal. Sometimes you can get an issue fixed by correcting errors.

When a simple correction might help

• Your name, Medicare number, or birth date was entered incorrectly
• The provider used the wrong billing code
• The provider mistakenly billed Original Medicare instead of your plan, or vice versa
• The same service was billed twice

In these situations:

• Contact the billing office of the doctor, hospital, or pharmacy
• Ask if they can rebill or correct the claim
• Confirm that they will resubmit to Medicare or your plan

If correction is not possible or the denial is based on a coverage rule, you may need to file an appeal.

Step 3: Know the Basic Medicare Appeals Levels

Most Medicare-related appeals follow five main levels, though the details can differ slightly between Original Medicare and Medicare Advantage/Part D.

Below is a general overview (always check your own denial notice for specific instructions):

Most people only go through Level 1 and sometimes Level 2. However, you generally do not have to pay again to appeal; you are usually disputing existing charges or coverage denials.

How to Appeal with Original Medicare (Part A and Part B)

If you have Original Medicare, your first appeal is usually called a redetermination.

Level 1: Redetermination by the Medicare Administrative Contractor

1. Find your Medicare Summary Notice (MSN)

   • The MSN lists your services and shows which were approved or denied

2. Check the “Appeals Information” section

   • Look for instructions that often say:
     • “If you disagree with this decision, you have the right to appeal”
     • Where to mail your appeal
     • The deadline to file (often within 120 days of receiving the MSN, but your notice may specify)

3. Prepare your appeal

   • You can:
     • Use the appeal request form often mentioned on the MSN, or
     • Write a letter that includes:
       • Your name, address, and phone number
       • Your Medicare number
       • The service(s) you are appealing
       • The date(s) of service
       • A clear statement: you “want a redetermination”
       • Explanation of why you believe Medicare should pay
   • Attach supporting documents, such as:
     • A letter from your doctor explaining why the service was medically necessary
     • Medical records relevant to the service
     • Bills or receipts

4. Send it to the address listed on your MSN

   • Keep copies of everything you send
   • Note the date mailed and consider using tracking

5. Wait for a decision

   • You will receive a written response explaining whether the decision changed

Higher appeal levels (Levels 2–5) are available if you disagree with the redetermination. The redetermination notice itself will explain how to move to the next level and the deadlines.

Appealing with a Medicare Advantage Plan (Part C)

If you are enrolled in a Medicare Advantage plan, you generally must follow your plan’s appeal process first.

Step-by-step for Medicare Advantage appeals

1. Review your plan’s denial notice

   • Look for:
     • The reason your plan denied coverage
     • Whether your case is handled as a standard or expedited (fast) appeal
     • How many days you have to appeal (often 60 days)

2. Contact your plan

   • Call the Member Services number on your plan ID card
   • Ask:
     • “How do I file an appeal?”
     • “Do I need a coverage determination or prior reconsideration first?”
     • “Where do I send written appeals?”

3. Ask for an expedited appeal if your health is at risk

   • You or your doctor can request an expedited (fast) appeal if:
     • Waiting the standard time could seriously jeopardize your life, health, or ability to regain maximum function
   • The plan will explain if your case qualifies

4. Submit your appeal

   • Include:
     • Your name, address, phone number, and plan ID number
     • A clear statement that you are appealing the denial
     • The service, item, or prescription in dispute
     • Dates of service or prescription
     • Supporting evidence:
       • A doctor’s statement about why it is needed
       • Relevant medical records

5. Next steps if the plan upholds the denial

   • Your plan must send you a written decision
   • If you disagree, your case can usually be automatically sent to an Independent Review Entity (Level 2)
   • The decision notice will explain how to move forward

Appealing Medicare Part D Prescription Drug Denials

For Medicare Part D drug coverage, denials often involve:

• The drug not on the plan’s formulary
• Requirements for prior authorization
• Step therapy (needing to try a different drug first)
• Quantity or dose limits

Typical process for Part D appeals

1. Request a coverage determination

   • This is often the first step before an appeal
   • You, your doctor, or your representative can request one from your Part D plan

2. Ask for an exception if needed

   • You may request an exception when:
     • You need a non-formulary drug
     • You need a higher quantity or strength than the plan usually covers
   • Your doctor will often need to support this in writing, explaining why covered alternatives are not suitable for you

3. If denied, file an appeal

   • Use the instructions in the denial letter
   • Ask your doctor to provide medical justification
   • If a denial could seriously affect your health, you may request an expedited decision

4. Follow further appeal levels

   • If your plan upholds the denial, you can usually move through the same higher appeal levels as other Medicare decisions (Independent Review Entity, ALJ hearing, etc.)

Key Documents to Gather for a Medicare Appeal

Having the right paperwork can make a big difference. Below are common documents people gather when appealing Medicare denials:

• Denial notice (MSN, EOB, or plan decision letter)
• Appeal form (if your plan or Medicare offers one) or a written appeal letter
• Medicare card and/or plan ID card copies
• Doctor’s letter or statement explaining:
  • Why the service or drug is medically necessary
  • Why other alternatives are not appropriate
• Relevant medical records, such as:
  • Office visit notes
  • Test results
  • Hospital discharge summaries
• Bills or receipts for the denied service or drug
• Any previous approval letters for similar services (if applicable)

When you send documents:

• Keep copies of everything
• Note when and how you sent them (mail, fax, etc.)
• If possible, use a mailing option that gives you a delivery confirmation

Working with a Representative or Advocate

You can choose someone to help you with your Medicare appeal. This person is often called an appointed representative.

Possible representatives include:

• A family member or friend
• A caregiver
• A social worker or case manager
• An attorney or legal aid advocate

To name a representative, you usually must:

• Complete an official Medicare “Appointment of Representative” form, or
• Submit a signed statement that meets Medicare’s requirements

You can ask:

• The official Medicare helpline
• Your Medicare Advantage or Part D plan
• Your local State Health Insurance Assistance Program (SHIP)

for information on how to correctly appoint a representative.

Common Reasons Medicare Appeals Are Denied or Delayed

Knowing frequent problem areas can help you avoid them:

• Missed deadlines for filing appeals
• Incomplete forms or missing signatures
• Not including the denial notice with your appeal
• Weak or missing medical justification from a doctor
• Appealing to the wrong address or wrong entity
• Not clarifying which specific service or date you are appealing

To reduce delays:

• Carefully follow all instructions on your denial notice
• Double-check that all required sections are filled out
• Consider asking your doctor’s office or SHIP counselor to review your paperwork before you send it

If You Disagree with a Hospital Discharge or Skilled Nursing Facility Decision

Medicare has special “fast appeal” rights for certain situations, such as:

• Being told you must leave the hospital sooner than you think is safe
• Being told your skilled nursing facility (SNF), home health, or rehab coverage is ending

In these cases, you usually have the right to a quick, independent review.

Typical steps:

1. Read the notice you receive from the facility

   • It often explains:
     • When coverage is scheduled to end
     • Which Quality Improvement Organization (QIO) to contact
     • The deadline to ask for a fast appeal

2. Contact the QIO by the stated deadline

   • Use the phone number on the notice
   • Explain that you want a fast appeal of the decision to end coverage

3. Keep copies of all notices and write down:

   • The date and time you called
   • The name of the person you spoke with

These processes can vary slightly by region, so always follow the instructions on your official notice.

Alternatives and Backup Options If Your Appeal Is Not Successful

If your Medicare appeal does not result in coverage, there may still be options to explore:

• Ask about other covered services or drugs

  • Your doctor may recommend a different treatment that Medicare does cover
  • For prescription drugs, ask whether there is a covered alternative on your plan’s formulary

• Check for financial assistance programs

  • State Pharmaceutical Assistance Programs (SPAPs) in some states
  • Manufacturer patient assistance programs (for certain drugs)
  • Hospital or clinic financial assistance policies
  • Charitable foundations or disease-specific organizations

• Review your coverage for the future

  • During Medicare Open Enrollment or other enrollment periods, consider:
    • A different Medicare Advantage plan
    • A different Part D plan more suited to your needs
  • Use the official Medicare plan comparison tools or get help from SHIP

• Seek legal help in complex cases

  • For high-cost denials or complicated medical necessity disputes, some people consult:
    • Legal aid organizations
    • Nonprofit advocacy groups
    • Private attorneys familiar with Medicare issues

How to Make Sure You’re Using Official Medicare Channels

Because Medicare coverage can be confusing, some scams and unofficial services try to take advantage of people seeking help. To stay safe:

• Official Medicare contacts are generally:

  • The number on your red, white, and blue Medicare card
  • The number on your official plan ID card
  • Your local Social Security office
  • Your State Health Insurance Assistance Program (SHIP)

• Be cautious if:

  • Someone calls you unexpectedly, asks for your Medicare number, and pressures you to sign up for services or appeals
  • A website promises guaranteed approval or guaranteed appeal success
  • You are asked to pay large upfront fees for simple appeal help that is often available free from SHIP or nonprofit groups

To confirm you’re on an official channel:

• Use contact details from:
  • Your Medicare card
  • Official paper letters or notices you received by mail
  • Phone numbers provided by your state or county aging or benefits offices

If you are uncertain, you can also:

• Call 211 in many areas to be connected with local aging and benefits resources
• Ask to be referred to your local SHIP program or Area Agency on Aging

Quick Checklist: What To Do After a Medicare Denial

Use this as a short step-by-step reference:

1. Read the denial notice carefully

   • Identify what was denied and why

2. Confirm your coverage type

   • Original Medicare, Medicare Advantage, or Part D

3. Check deadlines

   • Note the last day you can file an appeal

4. Talk with your doctor or provider

   • Ask if the denial might be fixed through corrected billing
   • Request a supporting medical statement if you appeal

5. Gather documents

   • Denial notice
   • Appeal form or appeal letter
   • Doctor’s letter
   • Relevant medical records
   • Bills or receipts

6. Submit the appeal to the correct address

   • Use instructions from your MSN or plan denial letter

7. Keep records of everything

   • Copies of documents
   • Dates sent or faxed
   • Names and phone numbers of people you spoke with

8. Seek help if needed

   • Contact your State Health Insurance Assistance Program (SHIP)
   • Speak with your local benefits office, Area Agency on Aging, or legal aid if appropriate

Understanding Medicare coverage denials and appeals can help you make informed decisions and advocate for yourself through the official system. While HowToGetAssistance.org cannot file appeals or contact Medicare on your behalf, you can use this information to organize your documents, meet deadlines, and work directly with Medicare, your plan, and local assistance programs to pursue the coverage review you believe is appropriate.