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How to Fight a Denied Medicare Advantage Claim

Medicare Advantage Plans are extremely specific regarding how a claim must be filed in order to be approved for coverage. Many times, a denied claim is simply an error in the way in which the claim was filed. However, if you do not advocate for yourself with your doctor’s office and your health plan, you may never get those errors fixed.

As a result, your claim will remain denied, leaving you without coverage for important procedures and medical issues. It is up to you to know your rights and reverse the denial as soon as possible.

Understanding Your Medicare Advantage Denied Claim Notice

If your Medicare Advantage Health Plan denies your medical claim, you will receive a notice of denial. First, you must carefully review the notice to make sure all the provided information is correct. Many times, information will be incorrect, such as the wrong doctor name, the incorrect procedure, or even your name. If you find any of these errors, contact your insurance provider immediately to determine how to correct this information, which may lead to an approval of the claim.

The next key to understanding the notice of denial is to review the instructions as provided in the notice. The denied claim notice will provide a detailed list of instructions in order for you to file an appeal with your Medicare Advantage provider. This appeal may help you obtain approval for your claim.

Filing an Appeal with Medicare Advantage

The first step to filing an appeal for your denied claim is to have your physician write a letter. The letter should detail the reasons your physician feels you need the care, its benefits, and the harm of not having the care. It is essential to make sure this appeal is completed within sixty days of receiving the denial notice.

You have the right to ask for an expedited decision with this appeal. This means the provider must make a decision within 72 hours of the appeal being filed. However, this expedited decision can only be requested if you are in grave danger. Otherwise, you must wait the standard time period for a decision on the appeal.

If your health is not in danger, the Medicare Advantage provider has thirty days to decide on a claim for care not rendered, and sixty days for care rendered. Do not worry if the first appeal is denied. If that is the case, an independent entity will receive your claim to review it and either confirm or overturn the denial.

To learn more about the process of appeal for a denied claim with Medicare Advantage, contact the professionals at 1-844-236-0228. Our licensed insurance experts will be happy to answer any questions you have.