Question: What can I do if my Medicare claim is denied?
Answer: If your Medicare claim is denied, you can file an appeal if you disagree with a coverage or payment decision made by Medicare, your Medicare Advantage Plan, other Medicare health plan, or Medicare prescription drug plan.
For example, you can file an appeal if Medicare or your plan denies:
- A request for a health care service, supply, item or prescription drug you think you should be able to get.
- A request for payment of a health care service, supply, item or prescription drug you already got.
- A request to change the amount you must pay for a health care service, supply, item or prescription drug.
You can also appeal if Medicare or your plan stops providing or paying for all or part of a health care service, supply, item or prescription drug you think you still need. If you want or need help filing an appeal, you can appoint a representative, who can help you with the appeal steps. Your representative can be a family member, friend, advocate, attorney, doctor or someone else to act on your behalf. You can appoint your representative in one of a couple ways:
- Fill out an “Appointment of Representative” form (CMS Form number 1696). You can complete the form online or call 800-MEDICARE and ask for a copy to be mailed.
- Submit a written request that includes:
- Your name, address, phone number and Medicare Number (found on your red, white and blue Medicare card)
- A statement that you’re appointing someone as your representative to act on your behalf
- The name, address and phone number of your representative
- The professional status of your representative (like a doctor) or their relationship to you
- A statement authorizing the release of your personal and identifiable health information to your representative
- A statement explaining why you’re being represented and to what extent
- Your signature and the date you signed the request
- Your representative’s signature and the date they signed the request
If you’re appointing someone to help with your appeal, send the “Appointment of Representative” form or a written request with your appeal request to the Medicare Administrative Contractor (MAC, the company that handles claims for Medicare) or your Medicare health plan. Keep a copy of everything you send to Medicare as part of your appeal. If you have questions about appointing a representative, call 800-MEDICARE (800-633-4227). TTY users can call 877-486-2048.
In some cases, your doctor can make a request on your behalf without being appointed your representative:
- If you have a Medicare Advantage Plan or other Medicare health plan:
- Your treating doctor can request an organization determination or certain pre-service reconsiderations on your behalf, and you don’t need to submit an “Appointment of Representative” form.
- If you want your treating doctor to request a higher level of appeal on your behalf, you’ll need to submit the “Appointment of Representative” form or a written request to appoint a representative.
- If you have a Medicare drug plan:
- Your doctor or other prescriber can request a coverage determination, redetermination or reconsideration from the Independent Review Entity (IRE) on your behalf, and you don’t need to submit an “Appointment of Representative” form.
- If you want your doctor or other prescriber to request a higher level of appeal on your behalf, you’ll need to submit the “Appointment of Representative” form.