FAQ Friday: How to Appeal Denial of Coverage
An appeal is the action you can take if you disagree with a coverage or payment decision by Medicare or your Medicare plan. For example, you can appeal if Medicare or your plan denies:
- A request for a health care service, supply, item, or prescription drug that you think you should able to get.
- A request for payment of a health care service, supply, item or prescription drug you already got.
- A request to change the amount you must pay for a health care service, supply, item or prescription drug.
You can also appeal if Medicare or your plan stops providing or paying for all or part of a health care service, supply, item, or prescription drug you think you still need.
If you decide to file an appeal, you can ask your doctor, supplier. Or other health care provider for any information that may help your case. Keep a copy of everything you send to Medicare or your plan as part of your appeal.
How you file an appeal depends on the type of Medicare coverage you have:
- Get the “Medicare Summary Notice” (MSN) that shows the item or service you’re appealing.
- Circle the item(s) on the MSN you disagree with. Write an explanation of why you disagree with the decision. You can write on the MSN or on a separate piece of paper and attach it to the MSN.
- Include your name, phone number, and Medicare number on the MSN, and sign it. Keep a copy for your records.
- Send the MSN, or a copy, to the company that handles bills for Medicare (Medicare Administrative Contractor or MAC) listed on the MSN. You can include any other additional information you have about your appeal. Or, you can use CMS Form 20027. To view or print this form, visit CMS.gov/cmsforms/downloads/cms20027.pdf, or call 1-800-Medicare (1-800-633-4227) to have a copy mailed to you. TTY users can call 1-877-486-2048.
- You must file the appeal within 120 days of the date you get the MSN in the mail.
You’ll generally get a decision from the Medicare Administrative Contractor (MAC) within 60 days after they get your request. If Medicare will cover the item(s) or service(s), it will be listed on your next MSN.