If Medicare does not agree to pay for a service or item that a person has received, they will issue a Medicare denial letter. Medicare can deny coverage for many different reasons.
Medicare provides coverage for many medical services to people who are age 65 years and older. Individuals with certain disabilities and medical conditions can qualify for Medicare earlier.
On occasion, Medicare may not pay for some items or services. When this happens, Medicare will issue a letter to advise a person of the decision.
This article looks at why someone might receive a Medicare denial letter, the different types of denial letters, and how individuals can appeal.
Medicare issues an official letter, also known as a Notice of Denial of Medical Coverage, when it refuses to pay the total or a portion 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 for coverage or that a person has reached their benefit limit.
Individuals who receive denial letters have the right to appeal within a certain amount of time.
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 use a doctor who is 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.
An NOMNC informs an individual that Medicare is not continuing to cover care from one of the following facilities:
- a comprehensive outpatient rehabilitation facility
- a home health agency (HHA)
- a skilled nursing facility (SNF)
The HHA or other facility should give an individual a NOMNC at least 2 days before a covered service ends. This notice will include:
- when covered services end
- how to appeal if an individual feels the coverage is ending too soon
- how to contact the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) to request a fast appeal
Medicare issues several other types of denial letters.
Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN)
An SNF-ABN lets a beneficiary know in advance that Medicare will not pay for a specific service or item at an 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 that a person received or because Medicare does not consider specific tests to be 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.
An IDN tells someone that Medicare will no longer offer coverage or that it will cover a previously authorized treatment at a reduced level only.
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 people 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, they can file an appeal within 120 days.
The first step is to complete a Redetermination Request form. The summary notice 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:
- their name, address, and Medicare number
- a copy of the summary notice, clearly showing which items or services they are appealing
- a summary of why the individual feels the items or services should be covered
- a statement from the doctor or healthcare service provider that will help their appeal
Medicare should issue a Medicare Redetermination Notice, which details its 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:
- their name, address, and Medicare number
- details of the items or services, including dates and reason for the appeal
- a statement from the doctor or facility providing the service
- any other helpful information
The standard decision time is 30 days. However, if an individual’s health could worsen by waiting for a decision, they can request a faster response.
The insurance provider must advise a person of its 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 who prescribes the medication should give the person a statement that explains why Medicare should approve the appeal.
The appeals process has five levels that involve different reviewers.
For each level, Medicare sends a person a decision letter that includes instructions on what to do next. If an individual disagrees with a decision made at one level, they will move to the next.
The five review levels are:
- initial review and appeal from the person’s plan
- reconsideration by a qualified independent contractor or an independent review entity
- decision by the Office of Medicare Hearings and Appeals
- review by the Medicare Appeals Council
- judicial review by a federal district court if the claim is over a minimum amount
In 2024, the minimum claim amount that can be brought before the federal district court is $1,840.
If an individual does not understand why they have received the Medicare denial letter, they should contact Medicare at 800-633-4227. An individual with Medicare Advantage or a prescription drug plan can contact their 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.
If a person is concerned that Medicare may not cover a service, they can request preauthorization from their insurance company or Medicare before receiving the service.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
Medicare can deny coverage if a person has exhausted their benefits or if Medicare does not cover the item or service.
When Medicare denies coverage, it 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.