A partial denial means your Medicare Advantage plan paid for some services on a claim, or part of a charge, and denied the rest. Your Explanation of Benefits (EOB) shows which lines were denied, usually with a short code or note explaining why. Medicare's appeals booklet says the plan must send a notice explaining why it fully or partially denied a request, and you generally have 65 days from that notice to appeal.
How do I spot a partial denial on my EOB?
Look at each line as well as the total. On most EOBs, each service has columns like:
- Amount billed by the provider.
- Plan allowed or approved amount.
- Plan paid.
- Your share (copay, coinsurance, or deductible).
- Not covered or denied amount, sometimes with a code.
A partial denial often shows a dollar amount in the "not covered" column for one or more lines, or a "plan paid" of $0 on some lines while others were paid.
For a full walk-through of EOB columns, see how to read a Medicare Advantage Explanation of Benefits.
What's the difference between "your share" and "not covered"?
- Your share is your normal copay, coinsurance, or deductible under the plan. You usually owe this.
- Not covered or denied means the plan decided not to pay that part. Whether you owe it depends on the reason. Sometimes the provider has to write it off. Sometimes it's an error that can be fixed.
If the EOB says "you may owe" on a denied line, don't pay that part until you know why it was denied.
Why do plans deny part of a claim?
Common reasons you might see:
- No prior authorization on file for one service. See Medicare Advantage prior authorization denials.
- Out-of-network provider for part of the care, like an out-of-network anesthesiologist or lab. See Medicare Advantage out-of-network bills.
- Bundled service. The plan says one service is part of another and doesn't pay separately.
- Coding problem. The code doesn't match the diagnosis or the plan's rules. See what a CPT code is.
- Duplicate line. The same service was billed twice. See duplicate charges on a medical bill.
- Not a covered benefit, such as some dental, vision, or hearing services. See dental, vision, and hearing bills.
- Medical necessity. The plan says the service wasn't needed. See Medicare Advantage denial says "not medically necessary".
The EOB code or note usually points to one of these. If it's unclear, ask the plan.
Who should I call first?
It depends on the reason.
Call the provider's billing office first if it looks like a coding, bundling, prior authorization, or duplicate problem. They may be able to fix and resubmit the claim.
What to say to the provider:
"My Medicare Advantage plan denied part of the claim for my visit on [date]. The EOB shows line [number], [service], was denied with code [code]. Can you check whether it was coded or authorized correctly, and resubmit if needed? Please hold my account while you check."
Call the plan if you need to understand the denial or think the plan made a mistake.
What to say to the plan:
"I'm looking at my EOB for [date of service]. Line [number] was denied. Can you tell me the reason in plain words? Do I owe this amount, or is the provider responsible? If I disagree, how do I appeal?"
Write down the date, the name of the person, and any reference number.
Do I owe the denied amount?
Sometimes yes, sometimes no. Ask both the plan and the provider:
- In-network providers may not be allowed to bill you for some denials, like a missing prior authorization the provider was supposed to get. Ask the plan whether that applies.
- Non-covered benefits you chose to get may be your responsibility.
- Errors shouldn't be your cost once fixed.
Ask the plan to put its answer in writing if you can.