Medicare Says Coverage Wasn't Active on That Date

What This Means

The payer’s records show that the coverage it checked was not active on the date you received care. First confirm the service date, your enrollment dates, and which payer should have received the claim.

X12 describes reason code 26 as expenses before coverage and code 27 as expenses after coverage ended. These codes identify a coverage-timing issue; they do not establish why the records differ or whether a correction is available.

Why This Happens

• Coverage had not started. For Part B enrollment before your 65th-birthday month during your Initial Enrollment Period, coverage generally begins in your birthday month. Enrollment during that month or the next three months generally starts coverage the following month. General Enrollment Period coverage also starts the next month. Check Medicare’s start-date rules, including the rule for birthdays on the first of a month.
• Coverage ended. Check the actual termination notice and effective date; do not infer them from a rejected claim alone.
• The claim went to the wrong payer. A Medicare Advantage plan ending does not necessarily end your Medicare coverage. You may return to Original Medicare. Ask which coverage was responsible on the service date.
• The claim or enrollment record needs correction. Compare the provider’s service date and identifying information with your records, and ask Medicare to confirm the enrollment dates it has recorded.

Should You Appeal?

For an Original Medicare first-level claim appeal, the contractor must receive your request within 120 calendar days after you receive the MSN. Receipt is presumed five days after its date unless evidence shows otherwise. Do not let an enrollment inquiry delay a required appeal. Medicare Advantage has a separate plan appeal process; CMS describes its standard first-level filing period as 65 days from the denial notice date.

Some people qualify for earlier coverage under an enrollment rule. Under the Medicare special enrollment period for loss of Medicaid, eligible people who missed a Medicare enrollment period and lost Medicaid entirely on or after January 1, 2023 can apply from notification of the upcoming loss through six months after termination. They can choose coverage the month after enrollment or the first day of the month Medicaid was lost. Retroactive coverage requires paying the applicable Medicare premiums for those earlier months. Ask Social Security to determine your eligibility and available dates.

What To Do Next

1. Check which coverage applied on the service date. Call 1-800-MEDICARE (1-800-633-4227) and compare its information with your enrollment notices.
2. Ask the provider to check the claim. Confirm the service date against the bill or service records, and the name and Medicare Number against your current card. Ask whether the correct payer received the claim.
3. Identify the decision you disagree with. Follow the contractor’s claim appeal instructions for a payment denial. For an SSA entitlement decision, follow the SSA notice. Railroad Retirement Board cases have separate procedures.
4. Keep track of each deadline. Save the notices, proof of enrollment, and copies of any requests. A correction inquiry does not automatically extend an appeal deadline.
5. Get help if the records conflict. Your State Health Insurance Assistance Program (SHIP) provides free Medicare counseling.

Sources

• Medicare.gov: When coverage starts.
• Medicare.gov: Special Enrollment Periods for plans.
• SSA: Loss-of-Medicaid enrollment period.
• SSA: Medicare entitlement appeals.
• CMS: First-level redetermination.
• 42 CFR 405.942: Filing time frame.
• CMS: Medicare Advantage reconsideration.

Frequently Asked Questions