Learning Center: Appeals and Grievances

If you are on Medicare, you will receive a Medicare Summary Notice (MSN) by mail every three months. If you don’t want to wait until your MSN arrives in the mail, you can track your Medicare claims by visiting www.MyMedicare.gov.

Claims are normally available for tracking or viewing within 24 hours of processing. Every charge your health care providers or suppliers billed to Medicare during the three-month period should appear on your statement. Your statement will also show what Medicare actually paid your providers and suppliers.

What if my MSN indicates Medicare made a payment decision that I think is wrong?

You have the right to appeal if Medicare or your Medicare plan denies payment for a service you think Medicare is obligated to cover. This applies to prescription drugs as well as to doctor or other health-care provider services.

If Medicare has determined that a service is no longer medically necessary, you should ask your doctor or other health care provider for information to support your claim that the service is medically necessary.

I have Original Medicare. How do I file an appeal?

You’ll need the MSN showing the item you’re appealing. You can follow instructions on the back of the MSN or fill out a one-page Redetermination Request Form and send it to the Medicare contractor indicated on your MSN. Normally, you need to file your request within 120 days of receiving the MSN, and you can expect a decision from the Medicare contractor within 60 days after your request is received.

What if I’m enrolled in a Medicare Prescription Drug Plan?

You can get a coverage determination before purchasing prescription drugs. This will explain in writing whether a certain drug is covered under your plan and whether you meet requirements for having that drug covered. You can also request an exception in certain cases if your plan normally doesn’t cover a drug that your health care provider believes is medically necessary for you.

Your network pharmacist can show you a notice explaining how to make your request to your Medicare drug plan. Ask to see this notice if necessary.
If you’re enrolled in a Medicare health plan, call your plan for further information about how to file a grievance or appeal.

You can never be too careful when it comes to monitoring your health care claims. The same goes for every aspect of your health care. If you have questions about Medicare Part A, Part B, Medicare Advantage, Medigap, or any other health care matter, MedicareMall will be happy to answer them. Contact us now and we’ll lead you through the Medicare maze and help ensure that you have the knowledge and confidence you’ll need to make the best decisions about your health.


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