Receiving a notice that Medicare or your Medicare Advantage plan has denied a claim does not necessarily mean that you are responsible for the entire bill.
Claims can be denied for many reasons. Common examples include:
- Incorrect or incomplete billing information.
- The service was determined not to be covered.
- A Medicare Advantage plan required prior authorization.
- The provider was outside your plan’s network.
- Medicare or the plan requested additional medical documentation.
- The service did not meet the plan’s coverage or medical-necessity requirements.
- The claim was submitted incorrectly.
Start by reviewing your Medicare Summary Notice or Explanation of Benefits (EOB). Look for the reason the claim was denied and, most importantly, the amount the document says you may owe.
Then compare that information with any bill you received from the provider.
Do not automatically pay a large medical bill simply because a claim was denied. Some denials can be corrected by the provider, resubmitted, or appealed.
If you received a denial and do not understand the reason, contact Regional Financial Security Agency. We can help you review the information, understand what happened, and identify possible next steps.