July 2021: Troubleshooting Medicare Coverage Problems

Understand your Medicare notices

If you have Original Medicare, you typically receive a Medicare Summary Notice (MSN) from Medicare every three months. Your MSN is not a bill. To understand your MSN:

  • Read the definitions and descriptions of services carefully.
  • Check the notes section. This is where Medicare may further explain its payment decisions or give you other important information.
  • If a service you received is not covered, you should appeal. Instructions and deadlines regarding appeals will be on the final page of your MSN, titles “How to Handle Denied Claims or File an Appeal.”
  • If you are unsure of anything on your MSN, or if you lose an MSN or need a duplicate copy call 1-800-MEDICARE or visit medicare.gov.

If you have a Medicare Advantage or Part D prescription drug plan, you typically receive an Explanation of Benefits (EOB) from your plan each month. Your EOB is not a bill. Although each insurance plan has its own format for an EOB, there is certain information that must be included in each notice. To understand your EOB:

  • Read the information and the services listed in the notice carefully.
  • Check the notes section, including the footnotes. This is where the plan may explain its payment decisions.
  • If a service you received is not covered, you should appeal. Instructions on appealing the plan’s decision are listed at the end of the EOB. You can also contact your State Health Insurance Assistance Program (SHIP) for help making an appeal. To find your SHIP, call 877-839-2675 or visit shiphelp.org.
  • Call your Medicare Advantage Plan or Part D prescription drug plan if you have any questions or if you need a new copy of your EOB.

Learn Medicare coverage rules

You do not need to know all of Medicare’s coverage rules, but before getting a service, check to make sure Medicare covers it and if there are any steps you must take to receive it. If Original Medicare or your Medicare Advantage Plan does not cover a service, it may be because you did not follow coverage rules.

  • To learn about Original Medicare’s coverage of a needed service, call 1-800-MEDICARE, visit medicare.gov, read the relevant sections of your Medicare & You handbook, and/or speak with your provider.
  • To learn about how your Medicare Advantage Plan covers a needed service, call your plan, read your plan’s benefits handbook and/or speak with your provider.

Know who to contact for assistance when issues arise

1-800-MEDICARE: Contact Medicare to learn about coverage rules, to find health care providers and suppliers in your area that participate in Medicare, and to learn about Medigaps in your state.

Medicare Advantage or Part D Plan: Contact your plan with questions about your plan’s coverage rules and costs. You can also contact your plan to ask more about why it denied a service or to file a grievance about customer service or administrative errors.

Social Security Administration (SSA): Contact SSA for Part A and B enrollment and premium issues, address changes, or replacement Medicare cards.

Your Medicare Broker: Contact your Medicare Broker for personalized counseling around your Medicare.

Beneficiary and Family Centered Care—Quality Improvement Organization (BFCC-QIO): Contact the BFCC-QIO with complaints about the quality of your care. You can find your BFCC-QIO by visiting www.qioprogram.org/contact.

Senior Medicare Patrol (SMP): If you believe you may be experiencing Medicare fraud, first contact your provider or plan to check if they made a billing error. If there are no errors and you believe you are experiencing fraud, call your SMP by calling 877-808-2468 or visiting www.smpresource.org.