The Problem: Excessive Delays and Denials
- Treatment delays – Patients, including those with chronic conditions, sometimes wait weeks for approvals.
- Increased administrative burden – Doctors’ offices spend excessive time submitting paperwork and appealing denials.
- Unexpected out-of-pocket costs – When claims are denied, retirees may face steep bills or forgo care altogether.
Insurers’ Promises to Improve the System
- 24-hour decisions for urgent care cases
- 72-hour decisions for standard requests (down from the current 5-14 day average)
- Routine imaging (e.g., MRIs, CT scans)
- Physical therapy sessions
- Select prescription medications
- Clearer denial explanations
- Real-time status updates on authorization requests
- Easier appeals processes
What Retirees Should Do Now
- Review Your Plan’s Rules – Understand which services require prior authorization.
- Keep Detailed Records – Save all correspondence with insurers and healthcare providers.
- Appeal Denials Promptly – Many rejections are overturned upon appeal.
- Stay Informed – Follow updates from Medicare, your insurer, and advocacy groups like the National Chrysler Retiree Organization.
The Bottom Line
A sample letter to write to medicare.gov on a denied claim.
[Your Name]
[Your Address]
[City, State, ZIP Code]
[Your Phone Number]
[Your Medicare Number]
[Date]
Medicare Appeals
Medicare - [Your Medicare Contractor’s Name, if known]
[Address, if available]
OR Submit online at: [Medicare.gov Appeals Page]
Subject: Appeal of Denied Claim – [Claim Number/Service Date]
Dear Medicare Appeals Department,
I am writing to formally appeal the denial of my claim for [briefly describe the service or item denied, e.g., "a knee MRI performed on [date] at [facility name]"]. The reason for denial stated was [quote the denial reason from your Medicare Summary Notice (MSN), e.g., "service deemed not medically necessary"]. However, I believe this decision was made in error for the following reasons:
1. Medical Necessity – My physician, [Dr. Name], determined this service was essential for diagnosing/treating my condition, [briefly explain, e.g., "chronic knee pain unresponsive to prior treatments"]. Attached is a supporting letter from my doctor.
2. Prior Authorization – [If applicable, mention if prior authorization was obtained or if the provider assured coverage.]
3. Medicare Coverage Rules – This service appears to meet Medicare’s coverage criteria under [cite policy if known, e.g., "Medicare Policy Manual Section XYZ"].
4.Enclosed Documentation (copies, not originals):
*Medicare Summary Notice (MSN) showing the denial
*Doctor’s letter/medical records supporting necessity
*Any prior authorization or referral forms
*Other relevant correspondence
I respectfully request a redetermination of this claim and ask that you reconsider your decision. Please contact me at [your phone number] if additional information is needed. I appreciate your prompt attention to this matter.
Sincerely,
[Your Signature]
[Your Printed Name]
[Your Name]
[Your Address]
[City, State, ZIP Code]
[Your Phone Number]
[Your Medicare Number]
[Date]
Medicare Appeals
Medicare - [Your Medicare Contractor’s Name, if known]
[Address, if available]
OR Submit online at: [Medicare.gov Appeals Page]
Subject: Appeal of Denied Claim – [Claim Number/Service Date]
Dear Medicare Appeals Department,
I am writing to formally appeal the denial of my claim for [briefly describe the service or item denied, e.g., "a knee MRI performed on [date] at [facility name]"]. The reason for denial stated was [quote the denial reason from your Medicare Summary Notice (MSN), e.g., "service deemed not medically necessary"]. However, I believe this decision was made in error for the following reasons:
1. Medical Necessity – My physician, [Dr. Name], determined this service was essential for diagnosing/treating my condition, [briefly explain, e.g., "chronic knee pain unresponsive to prior treatments"]. Attached is a supporting letter from my doctor.
2. Prior Authorization – [If applicable, mention if prior authorization was obtained or if the provider assured coverage.]
3. Medicare Coverage Rules – This service appears to meet Medicare’s coverage criteria under [cite policy if known, e.g., "Medicare Policy Manual Section XYZ"].
4.Enclosed Documentation (copies, not originals):
*Medicare Summary Notice (MSN) showing the denial
*Doctor’s letter/medical records supporting necessity
*Any prior authorization or referral forms
*Other relevant correspondence
I respectfully request a redetermination of this claim and ask that you reconsider your decision. Please contact me at [your phone number] if additional information is needed. I appreciate your prompt attention to this matter.
Sincerely,
[Your Signature]
[Your Printed Name]
Notes:
- Deadline: You must file this appeal within 120 days of the denial date on your MSN.
- Tracking: Send via certified mail (if submitting by mail) and keep copies of all documents.
- Next Steps: If this appeal is denied, you have further appeal rights (reconsideration, hearing, etc.).
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