• Skip to main content
  • Skip to secondary menu
  • Skip to primary sidebar
  • Skip to footer
California Health Advocates

California Health Advocates

  • Contact
  • Home
  • About Us
    • Contact
    • Our Team
    • Mission
    • Education Services
    • About HICAP
    • Press
    • Testimonials
  • MEDICARE COUNSELING
  • Fact Sheets
  • Topics
    • The Basics
    • Prescription Drugs
    • Low-Income Help
    • Medigap
    • Medicare Advantage
    • Other Health Insurance
    • Appeals
    • Billing & Claims
    • Disabilities
    • Long-Term Care
    • Tribal Nations & Medicare
    • Health Care Reform
    • Advocacy & Policy
    • Glossary
  • Fraud & Abuse
  • Medicare Complaints
  • Blog
  • Donate

If Your Medicare Part A or Part B Claim Is Denied

California Health Advocates > Appeals > If Your Medicare Part A or Part B Claim Is Denied

Listen to our podcast on Medicare Part A & B Appeals – available in English and Spanish

An appeal is the procedure you follow if you disagree with a decision about your health care. It is a way to deal with a complaint about a treatment decision or service that is not covered. It is different than a grievance, which is a complaint regarding the way your Medicare health plan provides care. For example, you may file a grievance if you have problems with the cleanliness of a facility, reaching the plan’s customer service department, staff behavior or operating hours.

You have the right to appeal any decision regarding your Medicare services. If Medicare does not pay for an item or service, or you do not receive an item or service you think you should, you can appeal. Ask your doctor or provider for a letter of support or related medical records that might help strengthen your case.

You may appoint someone else — a family member, friend, caregiver or doctor — to be your representative in an appeal or complaint.

This section outlines the process for Original fee-for-service Medicare appeals. If a Part A or Part B claim is denied or not handled the way you think it should be, you can appeal the decision. You may request a formal Redetermination of the initial decision. Very few people do this, but more than half of appealed claims result in paid claims or higher payments.

Your rights to appeal are described on the back of the Medicare Summary Notice (MSN) you receive from Medicare each quarter. Previously known as the Explanation of Medicare Benefits, the MSN summarizes:

  • Treatment(s) you received during the quarter
  • Amounts your providers charged
  • Amounts Medicare paid
  • Amounts you owe (if any)

In this section, we’ve compiled information on the steps to take for both coverage and payment appeals, and expedited appeals, as well as how to file quality of care complaints.

Learn more:

  • Coverage & Payment Appeals

  • Expedited Appeals

  • Quality of Care Complaints

Primary Sidebar

Change Text Size

  • 100%  110%  120%  130%  

News & Blog Categories

  • Medicare Advantage
  • Low-Income help
  • Medicare & Disabilities
  • Medicare Basics
  • Prescription Drugs
  • Medicare & Other Health Insurance
  • Medicare Billings, Claims & Appeals
  • Health Care Disparities
  • Fraud & Abuse

—

  • COVID-19
  • Resources
  • Health Care Reform
  • Long-Term Care
  • CHA News

—

  • Advocacy & Policy
  • Letters and Comments to Policymakers
  • Legislative and Congressional Testimony
  • Policy Briefs

Send Us Comment

Do you have comments or concerns about your Medicare coverage? Issues regarding getting your needed prescriptions from your Part D plan, or a Medicare Advantage plan representative's marketing practices? Let us know at comments@cahealthadvocates.org.

We are dedicated to making Medicare's program work well for all beneficiaries. Your feedback from your own or your client's concerns and experiences with Medicare, will guide our Medicare advocacy efforts with key policy and decision-makers in both California and nationally with the Centers for Medicare and Medicaid Services (CMS) and Congress.

Archives

Donate Today

Footer

Sign up for our newsletter

Choose the news you'd like to receive

Important Links

  • About Us
  • Fact Sheets
  • Blog
  • Donate
  • Contact
  • Privacy Notice
  • Cookie Policy
  • Accessibility Statement

Follow Us

Copyright © 2023 · California Health Advocates · Web Design by TWK Web and Print Design · Log in