A Medicare denial is common, and it isn't the final word. You can appeal. In Original Medicare, you generally have 120 days from the date you get your Medicare Summary Notice (MSN). Medicare Advantage and Part D plans generally give you 65 days from the date on the plan's notice. If you'd rather talk to a person, reach a Turnout advocate by phone or online.
Why does Medicare deny claims, services, or drugs?
Many denials trace back to paperwork, not your health. Common reasons include:
- Medical necessity wasn't shown. Your records didn't show the care is needed.
- No prior authorization. Some plans require approval before certain care.
- A billing or coding error. A wrong code can stop a valid claim.
- Out-of-network care. Many Medicare Advantage plans limit which providers you can use.
- Drug plan rules. A drug may not be on the plan's formulary (its list of covered drugs), or the plan may require step therapy (trying a lower-cost drug first) or set a quantity limit.
Your appeal needs to answer the reason on your denial notice directly. Our guide to responding to an insurance coverage denial letter explains how to read one.
How do you know which type of Medicare you have?
- Original Medicare (Parts A and B): You carry the red, white, and blue Medicare card. Denials show up on your MSN, which Medicare mails every four months when you've had services.
- Medicare Advantage (Part C): A Medicare-approved private plan that replaces Original Medicare. Your card comes from the plan. Denials arrive as a plan letter, often titled "Notice of Denial of Medical Coverage (or Payment)".
- Part D: Drug coverage from a standalone or Medicare Advantage plan. Denials come from the plan or at the pharmacy counter.
How long do you have to appeal a Medicare denial?
Coverage | First step | Deadline |
|---|---|---|
Original Medicare | 120 days from getting your MSN | |
Medicare Advantage | 65 days from the date on the notice | |
Part D | 65 days from the date on the notice |
Calendar the date on your notice. If you miss it, Original Medicare can accept a late appeal for "good cause," such as serious illness, and plans may accept a late request explained in writing.
How do you appeal a Medicare denial, step by step?
Original Medicare (Parts A and B)
These steps follow Medicare.gov's guide to Original Medicare appeals.
- Circle the denied item on your MSN and write why you disagree, or use the Redetermination Request Form (CMS-20027).
- Add your name, phone number, Medicare number, and signature. Attach supporting records.
- Send it to the Medicare Administrative Contractor (MAC) at the address on your MSN.
- The MAC usually decides within 60 days.
Four more levels follow:
- Level 2: Reconsideration by a Qualified Independent Contractor (QIC), requested within 180 days.
- Level 3: A hearing with the Office of Medicare Hearings and Appeals (OMHA), requested within 60 days.
- Level 4: Review by the Medicare Appeals Council, requested within 60 days.
- Level 5: Review in federal district court, requested within 60 days.
Levels 3 and 5 require the disputed amount to meet a yearly minimum.
Medicare Advantage (Part C)
Medicare.gov's page on health plan appeals lays out the path.
- Read the plan's notice for the reason and deadline.
- Ask the plan for a reconsideration in writing, following the notice's instructions.
- The plan generally decides within 30 days for a service you haven't had, and 60 days for a payment request.
- If the plan keeps the denial, it must send your case to an Independent Review Entity (IRE) automatically. Later levels match levels 3 through 5 above.
Part D drug plans
These steps follow Medicare.gov's page on drug plan appeals.
- Ask your plan for a coverage determination. If the drug isn't on the formulary or costs too much at its tier, ask for an exception; your prescriber must send a supporting statement.
- If the plan says no, ask for a redetermination within 65 days.
- If it's still denied, ask the IRE for review yourself; this step isn't automatic for Part D.
When can you get a fast Medicare appeal?
If waiting could seriously harm your health, ask for an expedited decision. Medicare Advantage plans generally decide within 72 hours, and Part D plans within 24 hours.
Separate rules apply when covered care is ending, as Medicare.gov explains:
- Hospital discharge: You should get "An Important Message from Medicare About Your Rights." Contact your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), listed on the notice, no later than your planned discharge date.
- Skilled nursing, home health, or hospice ending: You should get a "Notice of Medicare Non-Coverage" at least two days before services end. Contact your BFCC-QIO by noon the day before.
What should you include with a Medicare appeal?
A doctor's letter explaining medical necessity often strengthens an appeal. Ask it to cover:
- Your diagnosis and how it affects your daily life
- Why this service or drug is medically necessary for you
- What's been tried, and why other options don't fit
- A direct answer to the denial reason
For a long-term condition such as chronic pain, ask the doctor to describe your treatment history. Add the denial notice, office notes, and test results. Put your name and Medicare number on every page, send copies, and keep originals. Here's how a Turnout advocate takes that coordination off your plate.
What mistakes can hurt a Medicare appeal?
- Waiting on a callback past the deadline. File first, then follow up.
- Sending it to the wrong place. Original Medicare appeals go to the MAC; plan denials go to the plan.
- Ignoring the denial reason.
- Skipping the fast appeal. If your health is at risk, ask for one.
- Stopping after the first no. You can go to the next level.
See also these caregiver paperwork mistakes.
What this means for you
- Find your notice today. Confirm your coverage type and note the deadline.
- Call your doctor's office. Ask for a letter of medical necessity and recent records.
- File the first-level appeal and keep copies. Ask for a fast decision if your health is at risk.
- Check for cost help. If you're left with bills, read about Medicare Savings Programs and Turnout's cost savings help.
Turnout's healthcare advocates can help. More guides are on the Turnout blog.
Turnout is not a law firm, and its professionals do not provide legal representation.
FAQ
Does a Medicare Summary Notice (MSN) denial mean I owe money? No. The MSN isn't a bill. Ask the provider to note your pending appeal.
What happens during a Medicare redetermination? Someone at the MAC not involved in the first decision reviews your claim and anything new you send.
Can I file a Medicare Advantage appeal for a prior authorization denial? Yes. Ask your plan for a reconsideration in writing by the notice's deadline. If waiting could seriously harm your health, ask for a fast decision with your doctor's support.
What is a Part D coverage determination? It's your drug plan's first decision on whether it'll cover a drug and how much it'll pay. You, your prescriber, or someone acting for you can request one.
What are the five levels of Medicare appeal? Redetermination, reconsideration by an independent reviewer, an OMHA hearing, Medicare Appeals Council review, and federal district court review.
It's your turn
A Turnout healthcare advocate can help you understand why Medicare said no, gather records from your doctors, and work through the appeal with you. Turnout's healthcare advocacy is covered by Medicare and many Medicare Advantage plans, so most members pay nothing out of pocket. You can also run Turnout's free benefits scan to see if you qualify for help with Medicare costs.