Medicare Appeal Denial Part B

Answer 1

Get Started

Medicare consists of two parts. Part B (Supplemental Medical Insurance) covers physician's services, certain outpatient hospital services (including emergency room visits), ambulances, diagnostic tests, laboratory services, certain preventive care services such as mammography and pap smear screening, outpatient therapy services, durable medical equipment and supplies, and home health care services not covered by Part A.

Medicare Part B pays 80% of approved charges for most covered services. The beneficiary is responsible for paying a $100 deductible each calendar year as well as the remaining 20% of the Medicare approved charges. The beneficiary may have to pay additional charges if the doctor providing the care does not agree to Medicare's approved charges.

Medicare Part B is a voluntary program and is partially financed through monthly premiums, deductions, and coinsurance payments. The balance is funded by the federal government.

This document provides a letter to request that Medicare review its decision on a Part B claim. Doctors, suppliers, and other providers of Part B services submit claims directly to Medicare. The provider will charge you for any part of the Part B deductible that you have not met and any coinsurance payments that you owe.

A written notice, such as a Notice of Noncoverage, from your doctor is not an official Medicare determination that Medicare will not consider a particular service reasonable or necessary and will not pay for it. Ask your doctor to submit a claim for payment to the Medicare carrier to obtain an official Medicare decision.

If you disagree with a decision on the amount Medicare will pay on a claim or whether services you received are covered by Medicare, you have the right to appeal the decision. The first step in the appeal process is to ask for a "review" of the decision. Many times the initial determination fails to sufficiently explain the reasons for the denial. By asking for a reconsideration or review, the basis for denial will be clarified.

Your appeal can be processed much more quickly if you include a copy of the notice(s) that you received about your claim. If you do not attach a copy of the "Explanation of Medicare Benefits" form to your appeal letter, you will need to describe the services, provide the name of the service provider, and indicate the date the services were provided.

This review must be requested by the patient in writing WITHIN SIX MONTHS after the date of the initial decision. (This period can be extended upon a showing of good cause.) You must request the review in writing and file it at an office of the carrier, the Social Security Administration, or the Health Care Financing Administration (HCFA) office. The address and phone number of the organization to contact regarding your appeal is contained on the notice informing you of the decision made on your request for payment.

You will receive a written response of the review explaining the reasons for the decision and advising you of your right to a hearing and how to request it. If you disagree with the review determination, AND if the amount in question is at least $100 but less then $500, then you have SIX MONTHS after the date of the review determination to request a hearing before the carrier's hearing officer. (This period can be extended upon a showing of good cause.) If you are considering requesting a hearing, you should contact your local social security office or your personal attorney regarding your appeal as soon as possible. Additional appeals are available and it is important that you carefully observe the time limit for requesting each appeal step.

You may also be able to request a review by telephone. Contact your local social security office for more information.