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What if Medicare will not pay for something?

If Medicare refuses to pay for something, they send you a “denial” letter. The denial says they will not pay.

If you think they should pay, you can challenge their decision not to pay. This is called “appealing a denial.” If you appeal a denial, Medicare may decide to pay some or all of the charge after all. They may “change or reverse the denial.” You can appeal if:

  • Medicare refuses to pay for a health care service, supply or prescription that you think you should be able to get.
  • Medicare refuses to pay the bill for health care services or supplies or a prescription drug you already got.
  • Medicare refuses to pay the amount you must pay for a drug.
  • Medicare stops paying for all or part of a service you think you still need.

Note

If you need help with an appeal, call the Medicare Advocacy Project at 1-800-323-3205 to apply for assistance.

Take action right away. You must appeal by the deadline. All appeals have deadlines. Different kinds of appeals have different deadlines. Your denial notice should tell you how much time you have to appeal.

It is very important to get your doctor to support your appeal. Ask your doctor for a letter. Ask your doctor to explain the medical reasons that you need the service Medicare is denying.

How you appeal depends on what part of Medicare you are appealing: original A or B, Part C, or a Part D plan. You may appeal each of these plans through several administrative steps.

If you do not receive a favorable decision, you may appeal to an Administrative Law Judge, then to the Medicare Appeals Council then to Federal Court.

Remember

1. Appeal on time;
2. Keep copies of all your paperwork; and
3. Try to get your doctor’s support.

If you are appealing a Part C or Part D decision, contact your plan for instructions on how to appeal.

If you have Part B Original Medicare, you should get a statement every three months. The statement is called a Medicare Summary Notice (MSN). It shows the services that were billed to Medicare. It also shows you if Medicare will pay for these services. At the bottom of the MSN, there are instructions on how and when to appeal.

If you appeal, Medicare will write back to you and tell you their decision. If they still deny your claim, the letter will include instructions for how to file the next step of the appeal.

If you need a particular medication and your drug company says it is not on their covered drug list, ask your doctor to file for an “exception.” Your doctor must explain that no other drug on the list is as effective as the drug you need, or the other drugs on the list will cause negative side effects.

If Medicare approves the exception, generally the approval lasts until the end of that plan year. If Medicare does not approve the exception you can appeal to a higher level and try to get another decision.

Produced by Greater Boston Legal Services, Massachusetts Legal Assistance Corporation, Community Legal Aid, and Massachusetts Law Reform Institute
Last Updated November 2013

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