When this happens
Medicare denied something, or a bill arrived that makes no sense. Here is what to do before you pay it.
A denial letter is written by a system for a system. It arrives in an envelope that looks like every other envelope, with a deadline inside it. Families either pay because they are tired or ignore it because they are overwhelmed. Both cost money. There is a third option.
Prefer to speak with someone? Call 628 234 2273 (NAV-234-CARE). Free initial call. No obligation.
Does this sound familiar?
You are probably here because of one of these.
You may have searched for
- “medicare denied claim what to do”
- “how to appeal medicare denial”
- “medical bill wrong what to do elderly parent”
- A Medicare Summary Notice says “not covered” and you cannot tell which service it means.
- A bill arrived from a provider you do not recognize for a date you cannot place.
- Home health, equipment or a test was denied as “not medically necessary”.
- The pharmacy said the medication needs prior authorization and nothing has happened since.
- You have been told to “call your insurer”, and your insurer told you to “call your doctor”.
- There is a deadline and you are not sure whether it has passed.
The part nobody explains
What is actually going on
Original Medicare has five levels of appeal and a 120-day window from the notice date for the first one. A large share of first-level denials are overturned when the missing documentation is supplied, because most denials are coding or paperwork errors rather than a clinical judgement. But the appeal has to come from the right party with the right information, and the doctor’s office has to participate.
Bills are a separate problem. Providers bill before Medicare has finished processing, secondary insurers cross over late, and errors are common. The Medicare Summary Notice, not the provider’s bill, is the document that tells you what you actually owe.
How a navigator helps
Your doctor recommends the care. We help you follow through.
One dedicated person who learns your situation, makes the calls, coordinates the next steps and follows up on what happens. Here is what that looks like for this situation.
We help you read the notice
Which service, which date, which reason code, which deadline. We translate the letter into plain English and tell you whether it is a denial, a request for information, or a bill that should wait for Medicare to finish.
We help you decide whether to appeal
Some denials are correct. Many are not. We help you understand which kind this is and, if it is worth appealing, what the doctor’s office needs to provide.
We coordinate with the doctor’s office
Appeals succeed on documentation. Your navigator communicates with the practice about the visit notes, orders and letters of medical necessity the appeal requires and follows up until they are submitted.
We help you check the bill against the notice
Line by line, against the Medicare Summary Notice and any secondary insurance statement, so you pay what is owed and question what is not.
We look for the programs that make bills smaller
Medicare Savings Programs, Extra Help for prescriptions, hospital financial assistance, manufacturer programs. If cost is the reason care is not happening, this is where we look first.
Medicare may cover Navigate Care.
Medicare Part B covers Community Health Integration services for eligible patients when everyday challenges are affecting their health or access to care.
Questions families ask
How long do I have to appeal a Medicare denial?
For Original Medicare, 120 days from the date on the Medicare Summary Notice for the first level (redetermination). Medicare Advantage plans have their own timelines, typically 60 days. The date is on the notice; we help you find it.
Can you file the appeal for my parent?
We are not attorneys and do not represent patients in appeals. We help you understand the notice, gather what is needed, and coordinate with the doctor’s office, which is where most appeals are won or lost. For complex or high-value cases we can point you to SHIP counselors and legal aid.
The bill is from the hospital, not Medicare. Should I pay it?
Not until you have compared it with your Medicare Summary Notice and any secondary insurance statement. Hospitals often bill before processing is complete, and errors are common. If the amounts do not match, the bill is questioned, not paid.
Does Medicare cover this kind of help?
Medicare Part B may cover Community Health Integration services for eligible patients when practical challenges are affecting their care. Sorting out coverage and cost is often one of those challenges. We check your parent’s coverage before anything starts.
Guides
Guides that go deeper on this
Our guides go deeper on each part of this situation. They are free, sourced and written for families doing this for the first time.
How to read a Medicare denial letter
It arrives in an ordinary envelope with a deadline inside. What each part means, how to find the real reason, and how to tell a paperwork problem from a real no.
How to appeal a Medicare denial, step by step
Five levels, real deadlines, and a first-level success rate that should make you file. What to send, what the doctor needs to write, and how Medicare Advantage differs.
Medicare Savings Programs and Extra Help: the benefits that pay your Medicare bills
Millions of older adults on a fixed income qualify for a state program that pays their Part B premium, and often every deductible and copay too. Most have never applied, because nobody told them it existed.
How to read a Medicare Summary Notice
What Medicare paid, how Medigap claims are forwarded, and what to check before paying a provider’s bill.
What “medically necessary” actually means to Medicare
It is the phrase behind almost every denial and almost every approval. Where it comes from, how it is decided, and how to make a request meet it.
How to read a medical bill — and fight the ones that are wrong
A surprising share of medical bills contain errors. Here's how to spot them, dispute them, and stop paying out of fear.
Medicare applications and appeals, step by step
Enrollment windows, plan choices, denials and the appeal ladder — the paperwork side of Medicare, translated.
Often goes with
Pay what is owed. Question the rest.
Tell us what is happening. We will listen, check whether Navigate Care can help and explain the next step.
Or call 628 234 2273 (NAV-234-CARE). Free initial call. No obligation.