Free Medicare appeal help is available from your State Health Insurance Assistance Program (SHIP), from 1-800-MEDICARE (1-800-633-4227), from your doctor's office, and from your Medicare Advantage or drug plan's member services line. Before you file, review the bill and your Medicare notice closely, because some "denials" turn out to be billing errors that the provider can fix with a corrected claim. If an appeal is still needed, follow the instructions and deadline printed on your own Medicare Summary Notice or plan denial letter.
Who can give me free Medicare appeal help?
Your SHIP counselor. Medicare.gov lists SHIPs as a source of free health insurance counseling, including help to file a complaint or an appeal. Find your state's SHIP at shiphelp.org or by calling 1-800-MEDICARE.
1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048). Medicare can explain why a claim was denied and how the appeal process works.
Your doctor or other provider. Medicare.gov suggests asking your provider for any information that could make your appeal stronger, like a letter explaining why the care was needed.
Your plan. If you have Medicare Advantage or a drug plan, member services can tell you how to start an appeal and what the plan needs.
A representative. You can name someone, like an adult child, to handle the appeal for you. Medicare uses form CMS-1696, Appointment of Representative, for this. Form CMS-10106 lets 1-800-MEDICARE share your information with someone you choose, but it doesn't make them your appeal representative.
Why should I review the bill before I appeal?
An appeal asks Medicare or your plan to change a coverage decision. But not every unpaid line is a coverage problem. Sometimes the provider:
- Used the wrong billing code.
- Left off information Medicare needed.
- Billed the same service twice.
- Billed you before Medicare or your Medigap plan finished processing the claim.
In those cases, a call to the billing office asking for a corrected claim may solve it faster than an appeal. If it doesn't, you'll know more about what to argue.
What should I check first?
Put the bill next to your Medicare Summary Notice (MSN) or your plan's Explanation of Benefits (EOB) and look at:
- The denial reason. Each denied line on an MSN has a code and a short explanation.
- The dates and services. Make sure you actually got what's listed.
- "Maximum you may be billed." That's the most the provider can charge you for that line.
- Duplicates. The same service listed twice on one day can be a mistake.
- Your appeal deadline. It's printed on the MSN or denial letter. Write it on your calendar.
For more detail, see how to read your Medicare Summary Notice and common medical billing errors seniors should check for.
What do I say to the provider before appealing?
Script:
"I'm calling about [patient name], date of service [date]. Medicare denied [service] with the reason [read it from the MSN]. Can you check whether this was a coding or billing error that you can correct and resubmit? If it was billed correctly and Medicare still won't pay, can you give me a letter explaining why the service was medically necessary? I'd like to include it in an appeal."
Write down who you spoke with, the date, and what they said.
What if I have Original Medicare?
Original Medicare has 5 levels of appeal. The first is a "redetermination" by the company that processes Medicare claims. Medicare.gov says you can follow the instructions on your MSN: circle the item you're appealing on a copy of the MSN and send it with your explanation, or fill out a Redetermination Request Form. Send copies, keep the originals.
The full step-by-step process is in how to appeal a Medicare denial, step by step.