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How to handle a Medicare Appeal

by | Articles, Law, Medicare

How to Handle Denied Claims or File an Appeal

If a claim was denied, call or write the provider and ask for an itemized statement for any claim. Make sure they sent in the right information. If they didn’t, ask the provider to contact our claims office to correct the error. You can ask the provider for an itemized statement for any service or claim.

Call 1-800-MEDICARE (1-800-633-4227) for more information about a coverage or payment decision, including laws or policies used to make the decision.

If You Disagree with a Coverage Decision, Payment Decision, or Payment Amount, You Can Appeal

Appeals must be filed in writing. Use the form to the right. Our claims office must receive your appeal within 120 days from the date which you receive your official Medicare Summary Notice listing this claim.

If You Need Help Filing Your Appeal

Call 1-800-MEDICARE or your State Health Insurance Program for help before you file your written appeal, including how to appoint a representative.

Call your provider: Ask your provider for any information that may help you.

Ask a friend to help: You can appoint someone, such as a family member or friend, to be your representative in the appeals process.

Contact an attorney.

Find Out More About Appeals

For more information about appeals, read your “Medicare & You” handbook or visit www.medicare.gov/appeals.

File an Appeal in Writing

Follow these steps:

  1. Print your Medicare Summary Notice.
  2. Circle the service you disagree with on the notice.
  3. Explain in writing why you disagree with the decision. Include your explanation on the notice or, if you need more space, attach a separate page to the notice.
  4. Fill in all of the following:

    Your telephone number

  5. Include any other information you have about your appeal. You can ask your facility for any information that will help you.
  6. Write your Medicare number on all documents that you send.
  7. Make copies of the notice and all supporting document for your records.
  8. Mail the claim and all supporting documentation to your Medicare Claims Office at either the address listed  your claim form, if there is no address listed below, the address for the Medicare Claims Office on your official Medicare Summary Notice.  For example, one appeals office is:

Medicare Claims Office
c/o Palmetto (GBA) – 11004ALRHHIB
Palmetto GBA J11 HHH Appeals
Mail Code: AG-630 PO Box 100238
Columbia, SC 29202-3238