Understanding Medicare Denials and How to Appeal Them

It is mostly common that out of 100 just 10% of claim denials happen around a year in medicare industry. It is better to understand and look forward in solving the issue rather than quitting of claiming insurance. You have full rights to get claimed for the reimbursement you applied for. Here are some ideas explained how to appeal your reimbursement.

You must be clear whether the medicare had denied to your claim or just rejected it. Mostly rejections don’t happen unless and until the information which you provided is completely fake. If it is denial it can be taken into care and claimed again for getting your reimbursements.

Check your claim

There may be several conditions in your claim which the medicare industry must not have understood properly. You must be quite aware for what reason they did not sanction your claim.  There are several reasons where the insurance provide will not sanction your claim. Such conditions are mentioned below

You may not get reimbursement for plastic surgery, teeth whitening, herbal treatments, illegal operations and many more. So be aware of the treatment that is given to you.

  • They deny for expensive medicines
  • Post hospitalization and pre hospitalization process
  • Not clear billing statements

These are some main reasons why your claim has been denied. If this becomes any one of your condition then you can go with four options like

  • Redetermination
  • Reconsideration
  • Appeal for Administrative Law Judge
  • Federal Court


This will be your plan A and you have to file an appeal before completion of 120 days of denied claim. You can submit a clearly explained statement for predetermining your denial. The clear statement will be called as Medicare Summary Notice (MSN). You can give clear points on MSN.


If plan A fails again then go with plan B, mostly within plan B all your claims will be reconsidered and sanctioned without any further delay. It involves a Qualified Independent Contractor for sanctioning your reimbursement as soon as possible. This must be filed within the completion of 180 days after the rejection of redetermination which was your plan A.

Appeal for Administrative Law Judge

This can be your plan C. This is quite serious step in considering your medical claim. It happens in a general way of video conference or a phone call from a judge and you will be given chance to speak out for you claim. This appeal must happen within 60 days of rejection of your reconsideration or plan B.

Federal court

When you are lost in plan C you have a last plan to carry out which may become your master plan D. This involves the court room where your lawyer will speak on your behalf and on whole the insurance company’s head will be called for and asked for proper reasons for your claims denials. Based on where the truth is the judgment will be sentenced. This must be carried out within 60 days of rejection of your plan C which was your Appeal for Administrative Law Judge.

These are the approaches which deal with denial of medical claim.

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