Medicare claim denial may take any Medicare beneficiary by surprise. Perhaps you, too, have been shocked to find that Medicare denied a claim that you were sure would be paid. Medicare offers broad, comprehensive medical and hospital coverage for eligible beneficiaries and can pay for most medically necessary services. A little known Medicare secret is that Medicare's coverage guidelines are far more flexible and far less restrictive than those of most private insurance companies. However, sometimes Medicare claims may deny for seemingly incomprehensible reasons. The chances are that if you have experienced a Medicare claim denial, you have fallen prey to one of the 5 basic reasons for Medicare claim denial. This article will tell you what they are, and what you can do to see that Medicare reverses its denial and pays on your claims.
Provider Error
The number one reason for claim denial in the Medicare system is probably due to error in either the way the claim is submitted or in the information provided. This often occurs when the provider omits information needed by Medicare to process the claim. In some cases, this may lead Medicare to think that the services are not medically necessary. In other cases, a provider may bill Medicare for the wrong service. When these situations arise, it is necessary to advise the provider to either get Medicare the information it needs to process the claim, or advise the provider to resubmit the claim for the service you received. A common example of provider error is when a beneficiary receives a covered pap and pelvic exam, but the doctor office bills these services as an office visit. In such a case, Medicare will deny the claim. This is easily corrected by the doctor office resubmitting the claim and billing Medicare for the exact services received.
Medical Necessity Denials
