For many, Medicare Part A (hospitalization) and Medicare Part B (Medical) denials are due to reasons such as not meeting medical necessity; frequency limitations; and even basic coding mistakes.

Denials are subject to appeal, since a denial is a payment determination. It is beneficial for an individual to understand why they have received a Medicare denial letter.

Medicare’s reasons for denial for Part A and Part B can include:

¯ Medicare does not deem the service medically necessary.

¯ A person has a Medicare Advantage plan, and they used a healthcare provider outside of the plan network.

¯ The beneficiary has reached the maximum number of allowed days in a hospital or care facility.

WHAT IS A MEDICARE DENIAL LETTER?

Those who receive a Medicare denial letter can choose to appeal it. Medicare issues an official letter, also known as a Notice of Denial of Medical Coverage, when they refuse to pay the total or a proportion 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, or that a person has reached their benefit limit.

Carefully reading a denial letter can help a person find out the next steps. Medicare issues several types of denial letters.

¯ Notice of Medicare Non-Coverage (NOMNC) — A Notice of Medicare Non-Coverage (NOMNC) informs an individual that Medicare is not continuing to cover care from a comprehensive outpatient rehabilitation facility (CORF), a home health agency (HHA), or skilled nursing facility (SNF). Medicare must notify someone at least two calendar days before the coverage ends.

¯ Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) — A Skilled Nursing Facility Advanced Beneficiary Notice (SNF-ABN) lets a beneficiary know in advance that Medicare will not pay for a specific service or item at a skilled nursing facility (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 received, or because specific tests are not considered 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. It tells someone that Medicare will no longer offer coverage, or that they will only cover a previously authorized treatment at a reduced level.

MOST COMMON REASONS FOR MEDICARE A & B DENIALS:

¯ Non-Covered by the Contractor – claims must be submitted to the correct payer. Updates made to patient files could cause an overlap in health insurance coverage dates/contractors resulting in this type of denial.

¯ Code Submitted is incorrect – incorrect coding for service provided does not match

¯ Payment is Included in Another Service Previously provided – cannot charge for the same service received by another provider

¯ Medicare is the Secondary Payer – When Medicare is secondary, the primary payer must be billed first

¯ Expense Incurred Prior to Coverage/After Coverage Ended – check patient eligibility to ensure there is Part B coverage. Also, verify there have been no lapses in coverage.

¯ Patient is enrolled in Hospice – Patients waive Medicare Part B payments for professional services related to the terminal prognosis when Hospice coverage is selected.

¯ Time limit for Filing has Expired – claims for services must be filed within one calendar year (12 months) after the date of service.

MOST COMMON DENIALS FOR PART D (PRESCRIPTION) COVERAGE

There are several reasons why your Medicare Part D plan might refuse to cover your drug.

¯ Drug is not medically necessary

¯ Not on the plan’s formulary

¯ Doctor did not obtain prior authorization from the Part D plan

¯ Doctor prescribed a dosage that is not covered by Medicare Part D

¯ Doctor prescribed a form (liquid vs. pill) or type (generic vs. brand) that is not covered by Part D plan

¯ Part D plan removed the drug from its formulary

¯ Cannot use a pharmacy that is not in-network with Part D plan

¯ Drug is not covered by Medicare Part D

APPEALS

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 those with a Medicare Advantage plan, their insurance provider allows 60 days to appeal.

Original Medicare A & B Appeals

If someone disagrees with a payment decision shown in their Medicare Summary Notice (MSN), they can file an appeal within 120 days.

The first step is to complete a Redetermination Request Form. The MSN 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:

¯ name, address, and Medicare number

¯ copy of the MSN clearly showing which items or services they are appealing

¯ summary of why the individual feels the items or services should be covered

¯ statement from the doctor or healthcare service provider that will help their appeal

Medicare should issue a Medicare Redetermination Notice, which details their 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:

¯ name, address, and Medicare number

¯ details of the items or services, including dates and reason for the appeal

¯ a statement from the service provider

¯ any other helpful information

The standard decision time is 30 days, but if an individual’s health could suffer by waiting for a decision, they can request a faster response. Here, the insurance provider must advise of their decision within 72 hours.

MEDICARE 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 or healthcare professional who prescribes the medication should provide a statement that explains why Medicare should approve the appeal.

So if you should ever have a denial for a service or a medication, know that you have the ability to appeal the decision working with your provider to get the coverage and medications you need.