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    Medicare Question

    Recently had different lab work done on different dates. The MSN states ***One or more procedures/services may have been denied by Medicare. (There obviously were denied as Medicare made no payment and my supplemental policy denied the claims as Medicare didn't pay.)
    Why doesn't Medicare have to give a reason for their denial? And, how do you try to get the claim reprocessed when you don't know what was incorrect with the original claim? A preventative service was one claim.
    Insurance companies are required to give a reason - why isn't Medicare?

    #2
    Wish I had an answer for you. I can just commiserate. I have been told to "call Medicare." Very unsatisfying.

    Hope you get a helpful response. I'm sure there are more of us who have had this problem and frustration and someone out there has a useful answer.

    Good luck to us all!

    Comment


      #3
      Originally posted by its2much View Post
      Why doesn't Medicare have to give a reason for their denial? ...
      Insurance companies are required to give a reason - why isn't Medicare?
      On the part of the MSN that lists your claims (Your Claims for Part B), there's a column for "Service Approved?" that says Yes or No next to each service/billing code (the Yes or No definitely clears up the "may have been denied" part). The last column is for notes. For a denied claim, there should be a code that coincides with a reason for why the claim was denied. The reason might not be detailed or particularly enlightening. What codes are next to the denied services and what explanation goes with the code?

      Originally posted by its2much View Post
      A preventative service was one claim.
      Is it a covered preventive service? And if it's covered, do you meet the eligibility requirements? A covered service will be denied if you aren't eligible. The covered preventive services and eligibility requirements are on the Medicare website, so you can check that part out.

      Originally posted by its2much View Post
      And, how do you try to get the claim reprocessed when you don't know what was incorrect with the original claim?
      The last page of the MSN (How to Handle Denied Claims or File an Appeal) has a section called "Get More Details." What does that section of your MSN say?

      With most things, it's best to start from the beginning. So maybe the best place to start investigating is with the doctor who ordered the lab work. Then you can follow the trail from doctor to lab to see what was ordered, how it was billed, whether you're covered, and whether you have grounds to appeal the denial. Good luck.

      Comment


        #4
        Denial Code

        Thanks for your post but I still don't understand why there is no requirement to give a reason that the claim and/or service was not paid.
        The code is g. The narrative for code g is "g. ***One or more procedures/services may have been denied by Medicare."
        Seems like alot of time, energy, people will be involved to reprocess claims with service charges under $100 since one has to investigate why the service was rejected before it is actually reprocessed. (One is for $95; the other is $63. After it's approved and reprocessed, Medicare won't approve/pay the charges in full.)
        I don't know how one would appeal a claim with the reason indicated on these MSNs?

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