If you have Original Medicare and your health service or item was denied, you have the right to appeal. Check your Medicare Summary Notice (MSN) to see if Medicare has paid for your services and how much you may owe your provider.
A Medicare Summary Notice is a summary of health care services and items you have received during the previous three months. The MSN is not a bill. The contractor that processes your claims for Medicare will send you the MSN, so it may have the name and address of a private company on it. MSNs are usually mailed four times a year (quarterly) and contain information about charges billed to Medicare, the amount that Medicare paid, and the amount you are responsible for.
If your MSN says that Medicare did not pay for a service, and you think it should, call your doctor to make sure there was not a billing error before appealing. Note that you can also appeal if you signed an Advance Beneficiary Notice (ABN) (see Can I Still Appeal a Denial by Original Medicare if I Signed an Advance Beneficiary Notice (ABN)?). Before appealing, make sure that Medicare was billed and that you received a denial.
Follow the steps below if your health service or item was denied
- Start your appeal by following the appeal instructions listed on your MSN or Redetermination Request form. This includes circling the denied service listed and filling out the shaded section at the end of the MSN. Then, send your appeal to the Medicare Administrative Contractor (MAC) within120 days of the date on your MSN. (The MAC’s name and address are listed in the shaded section of your MSN.) This will start your appeal. The MAC should make a decision within 60 days.
- If your provider sends you a bill for this service, let your provider’s billing office know that you are in the process of appealing Medicare’s coverage decision.
- If you have a good reason for missing your appeal deadline, you may be eligible for a good cause extension (see When and How Should I Request a Good Cause Extension?).
- If your appeal is successful, your service or item will be covered. If your appeal is denied, you can move on to the next level by appealing to the Qualified Independent Contractor (QIC) within 180 days of the date listed on the MAC denial letter. The QIC may go by a different name in your area. Follow the instructions on the MAC denial notice to file your appeal. The QIC should make its decision within 60 days.
- If your QIC appeal is successful, your service or item will be covered. If your appeal is denied and your health service or item is worth at least $160 in 2019, you can choose to appeal to the Office of Medicare Hearings and Appeals (OMHA). You must file your OMHA level appeal within 60 days of the date on your QIC denial letter. If you decide to appeal to the OMHA level, you may want to contact a lawyer or legal services organization to help you with this or later steps in your appeal—but this is not required. OMHA should make a decision within 90 days.
- If your appeal to the OMHA level is successful, your service or item will be covered. If your appeal is denied and your health service or item is worth at least $160 in 2019, you can choose to appeal to the Council within 60 days of the date on your OMHA denial letter. There is no timeframe for the Council to make a decision.
- You may not receive an OMHA level decision within 90 days. If your appeal has spent more than 90 days at the OMHA level, you can ask OMHA to move the appeal on to the next level (the Council). Speak to an attorney to see if proceeding directly to the Council may be appropriate for you.
- If your appeal to the Council is successful, your service or item will be covered. If your appeal is denied and your health service or item is worth at least $1,630 in 2019, you can choose to appeal to the Federal District Court within 60 days of the date on your Council denial letter. There is no timeframe for the Federal District Court to make a decision.
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