What should I do? MSN shows some services not paid

The Chester County Department of Aging, through its APPRISE program of certified Medicare counselors, helps Medicare beneficiaries to understand the health care options specific to their health needs and financial resources. This is one in a series of articles prepared by APPRISE volunteers to help Medicare beneficiaries navigate this complex system.

Our last article explained the Medicare Summary Notice (MSN) and what it tells you about your Medicare coverage. In reviewing the MSN, you may notice that the summary on page 1 has a section on the right Your Claims and Costs This Period. If there is a NO on the question, “Did Medicare approve all services?” then you need to review the claim details to determine how to proceed. Note that there are letters at the end of each service line that tell you about that line’s payment. If something is denied, there will be a note at the bottom of the page that offers a brief explanation

First ask yourself if you had all the services listed for that date. If you wish more information about the denial, a good place to start is the number (1-800-633-4227) listed in the Get More Details section. This number connects you to a representative at Medicare that can explain more fully why a service was denied. This is particularly helpful if there is a billing error on the claim. While the representative will not give you the correct codes for the service you received, you may be told that the diagnosis and/or procedure code is incorrect for the service you received. This explanation will help you when contacting your provider about possible incorrect coding on the claim.

The next step is to talk to your provider’s billing office asking for assistance in correcting the claim if the Medicare rep told you it was a billing error. This is also the place to ask if the coding on the claim accurately reflects the service you received and the condition that required the service. The billing office can submit a corrected bill and an appeal is not necessary.

Were you advised by the provider that a service might not be covered? Did you sign a Notice of Non-Coverage given to you by the provider? If you believe that the service should be covered for your condition, then you will need to file an appeal. Any MSN with denied services will include information on how to appeal the decision as well as the time limits for filing the appeal. If you wish to appeal the decision, the form to be completed is included with the MSN. It is important that you follow the directions on the notice and complete the form accurately. Contacting the provider of the service to ask for additional medical information that would justify the service is a good first step. The provider can assist you in filing that information with your appeal.

There are five levels to the appeals process. The first level is a redetermination and you have 120 days to file the appeal. This appeal is handled by the organization that denied the claim. Levels 2-5 are handled by qualified Medicare contractors independent of the organization that initially denied your claim. Time limits apply at each level and some levels also include a dollar amount that must be exceeded to continue. At each level, you have the option to continue to seek a reversal of the denial of service or to just pay the disputed amount. Remember that you should keep copies of any documents sent. Additionally you should keep the date and time of the contact and the name and phone numbers of anyone that you spoke to about the appeal. The process is similar for Original Medicare, Medicare Advantage plans and Part D Drug Plans; however, the names of the levels may be different.

If you need assistance with your appeal, APPRISE counselors are available to answer any Medicare-related questions. You can contact a counselor by calling your local senior center to set up an appointment or leaving a message on the APPRISE help line at 610-3445004. You can also email us with questions at apprisechesco@outlook.com.