Social Security & Medicare Questions: Medicare Denying Coverage

Social Security & Medicare Questions: Medicare Denying Coverage

Q: Recently I visited a specialist to determine the cause of a chronic cough. As I was checking out, I learned that the doctor wanted me to undergo a series of high-tech tests that I followed through with. Medicare denied coverage for one of the most expensive tests. Now I have a bill for almost $1,045 that I can’t pay. What should I do? I have a Medigap plan.

A: When you receive health services, your doctor or other provider submits the claim to Medicare. You will receive your initial coverage determination through your Medicare Summary Notice (MSN). The MSN is sent to you quarterly listing the services and supplies billed to Medicare, treatments you received, amounts providers were charged, amounts Medicare paid, and amounts you owe, if any. If you get a notice that doesn’t look correct, or if your medical claim was denied, act promptly. The sooner you do, the more likely you are to get the decision reversed. Every so often Medicare or your Medicare Advantage plan may deny claims for services, tests, supplies or prescription that you have already received. There are all sorts of reasons for denial — often you can get the denial overturned.

1. Check your Medigap plan. Check your plan to see if it covers the service Medicare does not. For example, if you were billed “excess charges” from your healthcare provider, certain Medigap plans may cover those charges.

2. Carefully review bills and compare them to your Medicare Summary Notice. Make sure you got all the services, supplies, or equipment listed. If you paid the bill before you got your MSN, make sure you paid the right amount for your services. Keep copies of all bills and receipts.

3. Call the healthcare provider. Call your healthcare provider’s office to make sure they submitted the correct information, including your Medicare number. Often all that may be needed is specific additional information such a test result or physician referral that may be required by the coverage rules. The doctor’s office may need to resubmit the claim.

4. Appeal the denied claim. If you disagree with any decision, file an appeal following the steps described on the back of your MSN. File your appeal within the required time, usually 120 days of receiving your MSN, and include additional information that supports your appeal. Make copies for your records of everything you submit.

5. Get help filing your appeal. Contact your State Health Insurance Assistance Program (SHIP) that operates through many area agencies on aging. To find an SHIP counselor near you, visit online at or call Medicare at 800-MEDICARE (800-633-4227).