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What to do about Medicare Claim Denials?

1. Review the Denial Notice

  • Understand the Reason: Carefully read the Explanation of Benefits (EOB) or the Medicare Summary Notice (MSN) to understand why the claim was denied.

  • Check for Errors: Ensure there are no errors in the billing codes, patient information, or other details.

2. Contact the Provider

  • Verify Information: Reach out to the healthcare provider to confirm that the information submitted on the claim was correct and complete.

  • Request a Resubmission: If there was a mistake, ask the provider to correct and resubmit the claim.

3. Appeal the Decision

If you believe the denial is incorrect, you have the right to appeal:

  • File an Appeal: Follow the instructions on your EOB or MSN to file an appeal. You typically have 120 days from the date of the denial to do so.

  • Prepare Documentation: Gather all relevant documents, including medical records, doctor’s notes, and any other evidence that supports your case.

  • Write a Letter: Write a detailed letter explaining why you believe the claim should be approved. Include your Medicare number, the specific service or item denied, and any supporting documents.

  • Submit the Appeal: Send your appeal to the address provided on the denial notice. Make sure to keep copies of everything for your records.

4. Follow Up

  • Track Your Appeal: Keep track of your appeal status by contacting Medicare or your insurance provider regularly.

  • Be Persistent: Appeals can take time, so be patient and persistent.

5. Seek Assistance

  • Contact SHIP: The State Health Insurance Assistance Program (SHIP) offers free counseling and assistance with Medicare-related issues.

  • Hire a Medicare Advocate: Consider hiring a Medicare advocate or consultant if you need additional help navigating the appeals process.

  • Call Me: Sometimes I can sift through the information with you and figure out what is the best next step and assist you with it. 208-544-5011. Lisa

6. Understand Your Rights

  • Know Your Coverage: Familiarize yourself with your Medicare coverage and benefits to better understand what is and isn’t covered.

  • Exercise Your Rights: Remember, you have the right to appeal and to seek a fair review of your case.

By following these steps, you can effectively address Medicare claim denials and work towards a resolution.



 
 
 

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