Medicare & Appeals

Q:  Medicare didn’t pay for my last medical treatment. It has paid for this same treatment before, so I think there may be a mistake. What should I do?

A: You should be able to file an appeal if you feel there was an error made in your billing to Medicare. You may file an appeal when:

  • A health care service,supply, or prescription that you think you should get was denied.
  • A payment for health care services or supplies or a prescription drug you already got was denied.
  • A change to the amount you must pay for a prescription drug was denied.
  • A plan stops providing or paying for all or part of an item or service you think you still need.

How you file an appeal depends on the kind of Medicare coverage you have.

Original Medicare

If you have Original Medicare and want to file an appeal, get the Medicare Summary Notice (MSN) that shows the item or service that was denied. You must file the appeal within 120 days of receiving the MSN.

To file your appeal, follow the instructions on the back of the MSN, or fill out the Redetermination Request Form.

Medicare Advantage Plan

Your plan sends you materials each year that should explain how to file a complaint, grievance, or appeal. Follow the instructions specific to your plan.

Medicare Prescription Drug Plan

With a Medicare Prescription Drug Plan, you have the right to:

  • Get a written explanation of the coverage made by your plan called a “coverage determination”.
  • Ask for an exception to a drug if you or your prescribing doctor believe you need a drug that isn’t on your plan’s formulary.
  • Ask for an exception to a coverage rule.
  • Ask for an exception if you think you should pay less for a higher tier drug because your doctor believes it is the best option for you.

To do any of these things, you or your doctor must contact your plan by phone or in writing.

Services Ending

If you feel coverage of your services with a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehab facility, or hospice are ending too soon, you may ask for an expedited appeal to speed up the appeals process. You should call 1-800-Medicare.

If you have questions about the Annual Enrollment Period or any other questions about Medicare, call SHIP at 1-800-452-4800, 1-866-846-0139 TDD or online at www.medicare.in.gov.