Medicare does not cover all healthcare services. If Medicare denies coverage for a covered service, you can file an appeal. When you receive services that are not covered by Medicare, you will need to pay for those services out of your own pocket.
What Medicare Doesn’t Cover
Medicare Part A and Part B, also known as Original Medicare, will pay for specific medically necessary and preventive services. Part A covers inpatient care in a hospital or skilled nursing facility, as well as hospice care, some nursing home care, and part-time home health care. Part B covers outpatient care such as doctor and emergency room visits, vaccinations, annual preventive screenings, clinical research, ambulance services, mental health care, durable medical equipment, and limited outpatient prescription medications.
It’s no secret that Medicare coverage has gaps. Medicare will not cover long-term or custodial care; personal comfort items; routine care or examinations for hearing, vision, or dental health; chiropractic services; acupuncture; cosmetic surgery; routine podiatry care; and other services.
Original Medicare only covers certain prescriptions that require special handling or administration. For all other medications, you will want to purchase a separate Medicare Part D prescription drug plan.
When Medicare Refuses to Pay
If Medicare does not cover a service you received, they will send you a denial notice. The Medicare Summary Notice letter will state the reason for the denial. Read the reason to find out how you can appeal the denial.
You will be denied coverage if the item, test or service is not covered by Medicare. If Medicare does have coverage for the service, the denial letter will tell you why. Your medical provider will have submitted a claim form to Medicare requesting payment for the procedure. Those claim forms are sometimes not filled out correctly. If there was a problem with the claim form, you can call your medical provider and ask them to make the necessary changes before re-submitting the claim to Medicare.
Medicare makes stipulations for many of its covered services that limit the frequency of treatments or impose other restrictions to receiving those services. Claims can be denied because Medicare deemed the services you received to have been not medically necessary. If your denial notice says that this was the reason that Medicare will not cover the services, you can file an appeal.
Claims can also be denied if there are local coverage rules. In that instance, you can file an appeal.
Your denial notice will detail the steps of filing an appeal, and will give a time frame to do so. For assistance, contact your local legal services.
