If Medicare does not agree to pay for a service or item that a person has received, they will issue a Medicare denial letter. There are many different reasons for coverage to be denied.
Medicare provides coverage for many medical services to those aged 65 and over. Younger adults may also be eligible for Medicare if they have specific medical conditions.
On occasion, Medicare may not pay for some items or services, and they will issue a letter to advise their decision.
This article looks at why someone might receive a Medicare denial letter, the different types of denial letters, and how they can appeal.
Medicare issues an official letter, also known as a Notice of Denial of Medical Coverage, when they refuse to pay the total or a proportion of an individual’s request for coverage.
When a person receives a denial letter for a service or item that has previously been covered, it can mean that the service may no longer be eligible, or that a person has reached their benefit limit.
It is beneficial for an individual to understand why they have received a Medicare denial letter.
Medicare’s reasons for denial can include:
- Medicare does not deem the service medically necessary.
- A person has a Medicare Advantage plan, and they used a healthcare provider outside of the plan network.
- The Medicare Part D prescription drug plan’s formulary does not include the medication.
- The beneficiary has reached the maximum number of allowed days in a hospital or care facility.
Carefully reading a denial letter can help a person find out the next steps.
Medicare issues several types of denial letters.
Notice of Medicare Non-Coverage (NOMNC)
A Notice of Medicare Non-Coverage (NOMNC) informs an individual that Medicare is not continuing to cover care from a comprehensive outpatient rehabilitation facility (CORF), a home health agency (HHA), or skilled nursing facility (SNF).
Medicare must notify someone at least two calendar days before the coverage ends.
Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN)
A Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) lets a beneficiary know in advance that Medicare will not pay for a specific service or item at a skilled nursing facility (SNF).
In this case, Medicare may decide that the service is not medically necessary.
Medicare may also send the SNF-ABN to notify someone that they are approaching their number of covered days under Medicare Part A.
Fee-for-Service Advance Beneficiary Notice (FFS-ABN)
If Medicare refuses to cover services under Part B, they will send an FFS-ABN.
The reason for this notice can be that Medicare does not cover the type of therapy received, or because specific tests are not considered medically necessary.
Notice of Denial of Medical Coverage
Medicare may send a Notice of Denial of Medical Coverage or Integrated Denial Notice (IDN) to those who have either Medicare Advantage or Medicaid.
It tells someone that Medicare will no longer offer coverage, or that they will only cover a previously authorized treatment at a reduced level.
If an individual has original Medicare, they have 120 days to appeal the decision starting from when they receive the initial Medicare denial letter.
If Part D denies coverage, an individual has 60 days to file an appeal.
For those with a Medicare Advantage plan, their insurance provider allows 60 days to appeal.
Original Medicare appeals
If someone disagrees with a payment decision shown in their Medicare Summary Notice (MSN), they can file an appeal within 120 days.
The first step is to complete a Redetermination Request Form. The MSN lists the address to use under the appeals information section.
People can also send a written request rather than use the form. They must include the following:
- name, address, and Medicare number
- copy of the MSN clearly showing which items or services they are appealing
- summary of why the individual feels the items or services should be covered
- statement from the doctor or healthcare service provider that will help their appeal
Medicare should issue a Medicare Redetermination Notice, which details their decision within 60 calendar days after receiving the appeal.
Medicare Advantage appeals
If the insurance provider sends an initial denial notice, it will also outline the appeal process that a person must complete within 60 days.
Typically, an individual must provide the following information:
- name, address, and Medicare number
- details of the items or services, including dates and reason for the appeal
- a statement from the service provider
- any other helpful information
The standard decision time is 30 days, but if an individual’s health could suffer by waiting for a decision, they can request a faster response.
Here, the insurance provider must advise of their decision within 72 hours.
Part D appeals
When Medicare refuses to pay for a prescribed drug, an individual can request a coverage determination or an exception by completing a “Model Coverage Determination Request” form or writing a letter of explanation.
The doctor or healthcare professional who prescribes the medication should provide a statement that explains why Medicare should approve the appeal.
The appeals process has five levels involving different reviewers.
If an individual disagrees with a decision, they move to the next level.
For each level, Medicare sends a person a decision letter that includes instructions on what to do next.
The five review levels are:
- initial review and appeal from the person’s plan
- reconsideration by a Qualified Independent Contractor (QIC) or an Independent Review Entity (IRE)
- decision by the Office of Medicare Hearings and Appeals (OMHA)
- review by the Medicare Appeals Council (Appeals Council)
- judicial review by a Federal District Court if the claim is over a minimum amount
In 2020, the minimum claim amount that can be brought before the Federal District Court $1,670.
If an individual does not understand why they have received the Medicare denial letter, they should contact Medicare at 800-633-4227, or their Medicare Advantage or PDP plan provider to find out more.
With Medicare Advantage plans, if a person feels unsatisfied with how the insurance provider deals with their appeal, they can file a complaint with their State Health Insurance Assistance Program (SHIP).
If a person is concerned that Medicare may not cover a service, they can request pre-authorization from their insurance company or Medicare.
Medicare can deny coverage if a person has exhausted their benefits or if they do not cover the item or service.
When Medicare denies coverage, they will send a denial letter.
A person can appeal the decision, and the denial letter usually includes details on how to file an appeal.
Individuals should follow the appeals process carefully and stick to the time limits to help their plan provider deliver a decision as quickly as possible.