Medicare is designed to provide comprehensive coverage for a wide range of medical services to Americans aged 65 and above. Younger people may also qualify for Medicare coverage if they are diagnosed with specific medical conditions.

In most cases, Medicare will pay for covered services without any issues, but there may be a few exceptions where your claim is denied. So, what happens when Medicare denies your claim for a particular service or if a particular item you needed is no longer covered?

In such a case, you will be issued with a Medicare denial letter explaining why they denied your claim. You will have the right to appeal Medicare’s decision once you receive the letter.

This blog post discusses everything you need to know about the Medicare denial letter and how to file an appeal if you think the decision is unfair.

What Is a Medicare Denial Letter?

In simple terms, a Medicare denial letter is an official letter that Medicare issues when they fail to pay the whole or part of your request for coverage. The denial letter is also known as a Notice of Denial of Medical Coverage.

When you receive a denial letter for a service or item that has previously been covered, it means that the medical service or item could no longer be eligible for coverage or you have reached your benefits limit.

Types of Medicare Denial Letters

There are different types of denial letters depending on the situation and medical service involved. Below is a summary of the different types of Medicare denial letters:

1. Notice of Medicare Non-Coverage (NOMNC)

The Notice of Medicare Non-Coverage is usually sent to inform a Medicare beneficiary that Medicare will no longer cover care from a comprehensive outpatient rehabilitation facility, skilled nursing facility, or a home health agency. The law requires Medicare to notify you at least two days before coverage stops.

2. Skilled Nursing facility Advanced Beneficiary Notice

This type of denial letter is meant to notify a beneficiary of upcoming medical service or item at a Skilled Nursing Facility (SNF) that Medicare will not cover. In such a case, Medicare will have assessed the service and concluded that it is not medically reasonable or necessary.

The service may also be deemed custodial, meaning it is not medical-related. You may also receive this notice if you are close to meeting or exceeding your allowed days under Original Medicare Part A.

3. Fee-for-Service Advance Beneficiary Notice

If Medicare declines to cover any service under Part B coverage, they will send you a fee-for-service advance beneficiary notice explaining why they denied your claim.

The reason for this type of notice can be that Medicare doesn’t cover the type of therapy you received, or the specific tests ordered are not considered medically necessary.

4. Notice of Denial of Medical Coverage

This notice is specifically meant for Medicaid and Medicare Advantage beneficiaries which is why it is also referred to as Integrated Denial Notice. It is issued to notify you of denial of coverage in whole or part or to notify you that Medicare is reducing or discontinuing previously authorized treatment.

Why Did I Receive a Medicare Denial Letter?

Typically, Medicare will issue denial letters for a wide range of reasons. Some of these reasons include:

• You received services or items that your plan doesn’t consider medically necessary.
• Your prescription drug formulary doesn’t include a drug that your primary doctor prescribed.
• You are enrolled in Medicare Advantage (Medicare Part C) but went out of your plan provider’s network to receive medical care.
• You have reached your limit for the number of days you are allowed to receive care in a skilled nursing facility.

When you receive the Medicare denial letter, it will include specific information on why your claim was denied and the specific steps you need to follow to appeal the decision.

Filing an Appeal

If you are enrolled in Original Medicare, you will have up to 120 days starting from the day you receive the letter to appeal the decision.

If Medicare Part D denies your claim, you will have up to 60 days from the day you receive the denial letter to file an appeal.

If you are enrolled in Medicare Advantage, your plan provider will give you up to 60 days from the day you receive the letter to file an appeal.

1. Original Medicare Appeals

If you disagree with a payment decision shown in your Medicare Summary Notice, you have 120 days to file an appeal.

The first thing you need to do is complete the Redetermination Request Form. Your Medicare Summary Notice will list the address to use in your appeals information section.

You are also free to send a written request other than using the form. Ensure you include the following information on your written request:

• Full name, physical address, and your Medicare number.
• Statement from your primary doctor or healthcare provider that will help with the appeal.
• Summary of why you feel the medical services or items should have been covered.
• Copy of your Medicare Summary Notice showing the specific medical services or items you are appealing.

Medicare will issue a Medicare Redetermination Notice detailing their decision within 60 days of receiving your appeal.

2. Medicare Part C Appeals

If you are enrolled in Medicare Advantage, you will have up to 60 days to file an appeal from the day you receive the denial letter.

You will be required to provide your full name, physical address, Medicare number, statement from the service provider, and details of the medical services or items that were declined, including the specific dates they were declined.

Expect a decision within 30 days of submitting your appeal, but if you think your health could deteriorate further, you are free to request a fast response. In this case, the insurance provider must advise of their decision with three days.

3. Medicare Part D Appeals

When your prescription drug provider refuses to pay for a prescribed drug, you can request a coverage determination or an exception by completing the Model Coverage Determination Request form or write a letter of explanation.

The healthcare provider prescribing the medication should provide a comprehensive statement explaining why Medicare should approve your appeal.

Levels of Appeal

Once you receive your Medicare denial letter and decide to appeal the decision, your appeal will go through five steps, namely:

• Level 1: Redetermination from your plan.
• Level 2: Thorough review by an independent review entity.
• Level 3: Thorough review by the Office of Medicare Hearings and Appeals.
• Level 4: Complete review by the Medicare Appeals Council.
• Level 5: Judicial review by a federal district court.

It is critical to read and understand your denial letter to avoid further denials in the appeal process. You should also reread your plan’s rules to ensure you are following them and gather as much support from your healthcare provider as possible.

Typically, the more evidence you have to back up your appeals claim, the better. Ensure you fill out the appeals form accurately and, if possible, request an expert to go through your appeals before submission.

Summary

The truth is that Medicare can deny your coverage claim if you have exhausted your benefits or if the service or item you want covered is deemed unnecessary. When Medicare denies coverage, they will send a denial letter explaining why they took the decision.

From there, you have an option of appealing the decision so that the denied service or item is covered. Make sure you follow the appeals process carefully and observe the time limits to help your plan provider deliver a decision as soon as possible.

Do you still have questions about the Medicare denial letter or want help with filing your appeal? Contact us today to speak to one of our licensed insurance agents.