Medicare Denied or Is Ending Coverage
You can often appeal a Medicare denial.
But appeals can take work.
You may have to meet a short deadline, gather records, ask a clinician for supporting information, file more than one appeal, and keep track of every notice along the way.
Start with the notice in front of you.
Which Notice Do You Have?
- Care is about to end from home health, a skilled nursing facility, hospice, or certain rehabilitation services: see If Care Is Ending below.
- A claim was denied after the care under Original Medicare: see If Original Medicare Denied a Claim.
- A Medicare Advantage plan said no: see If You Have Medicare Advantage.
- The hospital says the person is being discharged: that’s a different process. See I Need Help With a Hospital Discharge →
- Not sure what you have: call 1-800-MEDICARE or your local SHIP before the deadline passes.
Look for:
- what Medicare or the plan says it won’t cover
- when coverage ends, if care is stopping
- why it was denied
- the appeal deadline
- where and how to file the appeal
Don’t wait for the next appointment if the deadline is close.
If Care Is Ending
If Medicare-covered care from a skilled nursing facility, home health agency, hospice, or certain rehabilitation services is ending, you should get a written notice before coverage stops. This applies to Original Medicare and Medicare Advantage.
If you didn’t get one, ask for it.
The notice explains how to request a fast appeal.
The deadline is short, often by noon of the day before covered services are scheduled to end. Follow the deadline and phone number on the notice. If you aren’t sure what to do, call SHIP or 1-800-MEDICARE right away.
Say:
“I disagree with the decision to end Medicare coverage. I want to file a fast appeal. What do I need to do before the deadline?”
Telling the facility, agency, or hospice that you disagree isn’t the same as filing an appeal.
Make sure the appeal itself has been filed with the organization named on the notice.
Ask the provider:
“Why does Medicare coverage end on [date], and what has changed that makes the care no longer covered?”
If Original Medicare Denied a Claim
Look at the Medicare Summary Notice.
It shows what was billed, what Medicare paid, and whether an item or service was denied. It isn’t a bill.
First, ask the provider whether the claim was submitted correctly. Sometimes missing or incorrect information can be fixed and resubmitted.
Say:
“Medicare denied this claim. Can you tell me why, and is there anything in the medical record that would support an appeal?”
If you still disagree, follow the appeal instructions on the notice.
For a first-level Original Medicare appeal, Medicare generally must receive the appeal within 120 days of the date you receive the Medicare Summary Notice. Follow the instructions and deadline on the notice.
If You Have Medicare Advantage
Start with the plan.
The denial notice should explain why the plan said no, how to appeal, and the deadline.
Follow those instructions closely.
If waiting for a standard decision could seriously jeopardize the person’s life, health, or ability to regain maximum function, ask for an expedited appeal.
Say:
“I want to appeal this denial. Waiting for the standard decision could affect [name]’s health. Please tell me how to request an expedited appeal.”
Expect Paperwork
An appeal may take more than one phone call.
Depending on the type of appeal, you may need to provide:
- the notice or claim number
- the Medicare number
- the service or item being denied
- dates of service
- the reason you disagree
- medical records
- a clinician’s statement
- proof that you’re allowed to act for the person
- confirmation that the appeal was received
The requirements can be strict.
A missing form, a missed deadline, or an appeal sent to the wrong place can slow the process or affect whether it’s considered.
Read each new notice when it arrives. Don’t assume the instructions will be the same as the last one.
Get the Clinician Involved When Medical Need Is the Issue
If the appeal depends on why the care is still medically necessary, ask the treating clinician for help.
Say:
“Medicare is denying or ending coverage for [care]. Will you provide information explaining why this care is still medically necessary?”
Ask for specifics, not just “patient needs continued care.”
Useful information may include:
- what skilled care the person still needs
- what could happen without it
- whether skilled care is still needed to improve or maintain the person’s condition, or prevent or slow decline
- why less care wouldn’t be safe or enough
- for an expedited appeal, why waiting could be harmful
If You’re Filing for Someone Else
If you’re handling the appeal for someone else, ask Medicare or the plan whether you need to be formally named as their representative.
There may be a form to complete before Medicare will discuss the case or accept certain actions from you.
Don’t assume being a spouse, child, caregiver, or health care decision-maker automatically gives you authority to handle the appeal.
Keep Everything
Save:
- every denial or termination notice
- the appeal itself
- confirmation that it was received
- supporting medical records or letters
- names and phone numbers of people you spoke with
- dates and times of calls
- reference or confirmation numbers
- every new appeal decision
Keep notes even if someone tells you the issue is being handled.
Don’t assume someone else filed the appeal. Confirm it.
If the First Appeal Is Denied
A first denial doesn’t always settle the issue.
Medicare generally has several levels of appeal. If you lose at one level, the new decision should explain whether you can move to the next level and what deadline applies. Higher levels can involve independent review and, later, formal hearings.
That can mean more paperwork and more waiting.
Some cases are approved only after further review. Others aren’t.
Read each denial carefully before deciding whether to stop.
If the amount of money is significant, care is still being denied, or the process has moved into formal hearings, you may want help from SHIP, an advocate, or an attorney.
Get Free Help With the Appeal
SHIP, the State Health Insurance Assistance Program, provides free, unbiased Medicare counseling.
A SHIP counselor can help you:
- identify the notice
- find the deadline
- understand which appeal process applies
- work through the paperwork
- understand what to do after another denial
Say:
“I have a Medicare denial or a notice that coverage is ending. I need help figuring out what kind of appeal this is, what I have to file, and when it’s due.”
Before You Rely on the Appeal
Make sure you know:
- exactly which decision you’re appealing
- the filing deadline
- where the appeal must go
- what documents are required
- whether it’s actually been received
- whether care continues while it’s pending
- what you may have to pay while the appeal is being decided
- what the next level is if you lose
Helpful Resources
Free, unbiased help understanding Medicare notices, coverage, and appeals.
Official Medicare instructions for Original Medicare, Medicare Advantage, drug plan, and fast appeals.
Learn More
Appeal packets and checklists for skilled nursing, home health, outpatient therapy, hospital discharge, observation status, and “improvement standard” denials.
