How do I appeal with Medicare for refusing a medical claim?

Hello Toni,

I have a $2,000 doctor bill with a new cardiologist, and Medicare says it will not pay. I recently retired and enrolled in Medicare and a Medicare supplement for the freedom to pick my own doctor!

This is too confusing for me. I need some advice. Thanks, Toni.

— Joey from Cleveland, Ohio

Hello Joey,

I rarely see a problem with a doctor’s/provider’s bills, but when it does happen, there is a process you must follow to find out if the office visit or procedure will be paid as a Medicare-approved service.

To find out if original Medicare will pay for care you received, visit medicare.gov and open an account to view your Medicare information and medical claims. For those not able to open a Medicare.gov online account, you can wait until you receive your Medicare summary notice.

Medicare summary notices are mailed four times a year and contain information about submitted charges, the amount that Medicare paid and the amount you are responsible for. Medicare summary notices are used only with original Medicare and not with Medicare Advantage or Medicare Part D prescription drug plans.

Below is what you should do if you believe the claim is medically necessary:

1. Find out if it is possible whether there was a billing mistake. Medicare uses a set of service codes, called CPT/ HCPCS codes, for processing medical claims. Each medical service has been assigned a specific code. Sometimes providers accidentally use the wrong codes when filling out Medicare paperwork, and this can result in Medicare denials. A denial can sometimes be easily resolved by asking your doctor to double-check that your claim was submitted with the correct code. Your doctor’s billing office can call 800-MEDICARE (800-633-4227) to verify the code. If a wrong code was used, ask your doctor to resubmit the claim with the correct code.

2. If the medical provider believes the claim was correctly coded or is unwilling to refile the claim, your next step is to appeal. Appealing is easy, and many Americans win.

Toni Says

The Medicare summary notice will have instructions on how to appeal. Follow those instructions. If the Medicare summary notice lists several items and you are not disputing all of them, circle the one you want to appeal. Write “Please review” on the bottom and sign the back. Make a copy for your files. Then mail the signed original to Medicare at the address on the Medicare summary notice. Make sure you mail your appeal within 120 days of receiving the notice.

3. If possible, get a letter from your health care provider stating the service was necessary and why. Send this with your Medicare summary notice.

4. If you need help filing your appeal, call Medicare at 800-633-4227. Normally, the wait to speak to a Medicare agent isn’t as long as the Social Security 800-number wait time, and Medicare is eager to help solve your issue.

5. Send your appeal certified mail with return receipt if using the post office, or ask for a signed delivery confirmation if using another delivery service (UPS, FedEx, etc.).

6. Always keep photocopies and records of all communication with Medicare, whether written or oral, concerning your denial.

Toni King is an author and columnist on Medicare and health insurance issues. She has spent nearly 30 years as a top sales leader in the field. If you have a Medicare question, email info@tonisays.com or call 832-519-8664. You can visit seniorresource.com/ medicare-moments to listen to her Medicare Moments podcasts and get other information for seniors. The publisher of Toni’s book, “Medicare Survival Guide Advanced” edition, is offering a $10 discount to Toni Says readers and friends at tonisays.com and seniorresource.com. The 2023 Medicare Prescription Drug Survival Guide is available at no cost by visiting tonisays. com.