What to do When Medicare is Rejected or Denied

Many people experience rejected Medicare claims. In most cases, a rejected claim is the result of missing information or putting information down incorrectly. For example, you may have neglected to put down the initial treatment date or you incorrectly wrote down the address of a facility. Mistakes are common, but less likely when you work with a Medicare insurance company in Boca Raton, such as the Center for Long Term Care Planning

In some cases, the claim is not rejected but denied. The two terms may seem interrelated, but they are quite different in regard to Medicare claims. 

When faced with a rejection, it is important to know the exact cause of the rejection and whether your claim was truly rejected or if it was denied. What is the difference between a claim denial and rejection? We will work to answer this question and explain the next steps if your claim was rejected or denied. 

Rejection vs Denial 

When you submit your claim for Medicare, you hope that it will be processed quickly and correctly. However, mistakes happen and as a result, rejections are all too common. The good news, when faced with a claim rejection, is that they are much easier to fix than denials. 

If your claim has been rejected, this means that the claim can’t be processed because the information you submitted was either incorrect, incomplete, or missing. The exact mistake should be mentioned in the rejection notice. To correct this mistake, you must correct the information and then resubmit the claim. 

A denied claim occurs when all the information provided was correct, but the hospital or doctor was not in your Medicare’s network, the care you received was not considered necessary, or the care provided can be covered by another insurance plan. For some, their claim was denied because they exhausted their benefits. 

These are just a few common reasons why a Medicare claim gets denied. When a claim has been denied, you are allowed to file an appeal if you think Medicare made a mistake in denying your coverage. A good time to appeal is if you were denied because the service was deemed unnecessary. You can argue that the service was medically necessary.

The Appeals Process 

Before you appeal, the first thing you want to determine is whether you filed a Medicare Advanced Beneficiary Notice of Noncoverage (ABN). If it turns out that you did not, then you are unable to file an appeal. Furthermore, it only works for traditional Medicare, which is Part A and Part B. In other words, it does not apply to Part C. Your provider should have asked you to sign an ABN if you planned to use Medicare to cover the expenses.

After you have determined that you signed an ABN, you should contact your doctor’s office to find out if the information they provided was correct. If a mistake was made, correcting it can save you from the daunting process of filing an appeal. If no mistake was made on their end and you think the denial was invalid, filing an appeal requires that you:

  • Gather all necessary information regarding your coverage 
  • Carefully read the claim denial for instructions on how to appeal
  • Contact your Medicare insurance agency to begin the appeal process
  • Fill out the Centers for Medicare and Medicaid Services Redetermination Request Form
  • Write a letter to the company that processed your Medicare Claim to explain why you plan to appeal

To ensure that you do not get denied a second time, reading and understanding your denial letter is critical. In addition to gathering necessary information about your coverage, reach out to medical providers to back up your appeal. Finally, before submitting your claim, review it a few times to make sure that all the information is accurate and filled out completely.

Who Can Help with Your Appeal?

Your healthcare provider may be able to help you when filing an appeal. If you are filing an appeal because you believe the medical care you received was necessary, your provider can back up your claim and explain why the test, prescription medication, or treatment was necessary, valid, and should be covered.

Contact the Center for Long Term Care Planning

Enrolling in Medicare should be easy, but is often challenging for individuals. If you are turning 65 or have another qualifying event, reach out for Medicare Insurance Help in Boca Raton. We will guide you through the process of enrolling and selecting the best plan. 

When you need a Medicare Insurance company in Boca Raton you can trust, contact Long Term Care Planning. Call (561) 272-0720 for a quote comparison.