Medicare Claim Denied? Here's What to Do
⚠️ Don't Panic — You Have Options
Many Medicare claim denials can be fixed or appealed. Start by understanding why your claim was denied.
Step 1: Understand the Denial
Check your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) for the denial reason. Common reasons include:
Service Not Covered
Medicare doesn't cover the service. Examples: cosmetic surgery, routine dental, most hearing aids.
Not Medically Necessary
Medicare didn't find the service medically necessary for your condition.
Billing Error
Wrong code, incorrect information, or claim submitted incorrectly.
Provider Not Enrolled
The provider isn't enrolled in Medicare or isn't in your plan's network.
Prior Authorization Required
The service needed pre-approval that wasn't obtained.
Step 2: Fix Common Issues
If it's a billing error
- Contact your provider's billing department
- Ask them to review and correct the claim
- Request they resubmit with correct information
- Get a reference number for tracking
If prior authorization was needed
Your doctor may be able to submit authorization retroactively. Contact your doctor's office and ask them to request an exception.
If the provider wasn't enrolled
Ask the provider to enroll in Medicare or your plan's network. Once enrolled, they may be able to resubmit the claim.
Step 3: File an Appeal
If you believe the denial was wrong, you have the right to appeal. There are 5 levels of appeal:
- 1
Redetermination
Request from your Medicare contractor within 120 days of denial.
- 2
Reconsideration
Request from a Qualified Independent Contractor (QIC) within 180 days.
- 3
Administrative Law Judge (ALJ)
Hearing if amount in dispute is $180+ (2026 threshold).
- 4
Medicare Appeals Council
Review of ALJ decision.
- 5
Federal District Court
Final level if amount is $1,840+ (2026 threshold).
📞 Get Free Help
Medicare: 1-800-633-4227 (24/7)
Your State SHIP: Free counseling on appeals
Medicare Rights Center: 1-800-333-4114