How to Read a Medicare Denial Notice before an Appeal

The Medicare Summary Notice (MSN) lists processed Part A and B claims, payments, and potential patient charges. It is not a bill. Review the denied item and appeal instructions. An Advance Beneficiary Notice of Non-coverage (ABN) warns that Medicare may not cover a proposed service but is not a claim denial. If a service is missing from the MSN, confirm whether the provider submitted a claim.

Medicare Advantage plans generally use the Notice of Denial of Medical Coverage (or Payment), also called the Integrated Denial Notice (IDN), for adverse coverage decisions. An Explanation of Benefits (EOB) may also serve as a formal denial notice if it meets applicable notice requirements. Check the denied service, decision date, coverage rule, and appeal instructions. If a provider reports refused authorization, request the plan's organization determination.

A pharmacy rejection may reflect prior authorization, formulary restrictions, or quantity limits without constituting an appealable coverage determination. Request a coverage determination or exception when appropriate. A denial notice explains the grounds and redetermination procedure.

Original Medicare appeals begin with a Medicare Administrative Contractor (MAC). Qualified Independent Contractor (QIC) reconsideration generally must be requested within 180 days after receiving an unfavorable MAC decision. Medicare Advantage plans ordinarily forward unfavorable reconsiderations for independent review. Part D beneficiaries generally request second-level review separately. Follow the latest decision's filing instructions. Additional Medicare appeals procedures apply at later stages.

Hospital discharge and termination of certain services can trigger expedited BFCC-QIO review. Hospital discharge appeals generally must be requested by the scheduled discharge day. For skilled nursing, home health, certain rehabilitation, or hospice services, the usual deadline is noon the day before termination. Other urgent Medicare Advantage and Part D decisions have separate expedited procedures. Follow the specific notice.

Compare the denied service with provider records, diagnosis codes, treatment dates, and authorizations. Providers may correct inaccurate claims. Keep:

• Denial notice and relevant dates.
• Claim details and authorization records.
• Clinical notes, tests, and physician statements.
• Appeal submissions and delivery confirmation.

Billing corrections do not necessarily suspend appeal deadlines.

A diagnosis alone may not satisfy Medicare coverage criteria. Identify the disputed requirement and supporting records. Skilled-care disputes may involve nursing assessments, treatment needs, and functional limitations. Diagnostic disputes may require test findings and clinical justification. A physician's statement should address the specific coverage criterion.

Part D exceptions generally require a prescriber's statement explaining medical justification. Evidence may include unsuccessful treatments, adverse reactions, or reasons covered alternatives are inappropriate. Address the plan's specific restriction.

Medicare coverage decisions generally follow federal appeal rules. Medi-Cal eligibility and Medi-Cal-only service disputes follow applicable state procedures. A Medicaid eligibility dispute concerns benefit qualification, not payment of an Original Medicare claim.

Medi-Medi Plans coordinate Medicare and Medi-Cal benefits. Certain integrated plans use a combined Coverage Decision Letter for applicable Medicare Part C and Medicaid decisions. Part D drug appeals remain separate. Check the benefit, plan type, and notice before filing.