Law Office of Richard M. Russell
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Falmouth, Massachusetts 02540

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Medicare Denials

 Medicare sometimes denies a medical bill.

You have the right to appeal a Medicare denial. People appealing a Medicare denial are frequently successful: The Medicare Rights Center states that 80 percent of Medicare Part A appeals and 92 percent of Part B appeals are successful.

What to do: If you have received a denial notice, review the notice, it states the reasons for the denial. Above all: make an appeal within the time stated in the denial notice (frequently but not always 60 days). 

Sometimes the denial is based upon a problem with the claim form, such as missing information, incorrect codes, or other error. When a claim form is incorrectly completed, it is likely to be rejected. If the claim form is rejected because it includes an error, contact your provider, the provider can correct the error and resubmit the claim. If the claim has already been processed, it may be necessary to submit a redetermination request.

The most frequent reason for a Medicare denial is that a service is not “medically necessary.” According to Medicare standards, a service is “medically necessary” if it treats an illness, injury, condition, or disease and meets accepted medical standards. If a claim is denied because a service was not “medically necessary,” an appeal can explain that the service was in fact actually medically necessary.

Frequently a denial states that treatment “does not support the need for this many visits . . .” This denial might follow several doctor visits. This determination also is appealable, for reasons similar to the “not medically necessary” denial. In appealing, explain why the service required multiple visits.

If you decide to appeal, ask your doctor, health care provider, or supplier for any information that may help your case. Remember, act within the applicable time limits.