Special Situations

These denials involve specific rules or situations that require targeted guidance. Each has its own resolution path.

• Charge on Medicare Statement You Don't Recognize
  Your Medicare Summary Notice shows a charge for a service you don't remember receiving. Learn how to verify the charge and report suspected fraud if needed.
• Medicare Bill Sent to Collections
  A Medicare bill you dispute has been sent to a collection agency. Learn your rights under the FDCPA, how to dispute the debt, and how to protect your credit.
• Medicare-Eligible but Kept Commercial Insurance
  You're over 65 with commercial insurance but didn't sign up for Medicare. Your plan is paying a fraction of your bills. Learn how retroactive enrollment can fix this.
• Part D Drug Costs More Than the Cash Price
  Your Medicare Part D copay is higher than paying cash or using GoodRx. Learn when to use your plan vs. pay cash, and how it affects your annual out-of-pocket cap.
• Medicare ABN (Advance Beneficiary Notice) Guide
  Your provider gave you an Advance Beneficiary Notice saying Medicare may not cover a service. Learn what an ABN means, your options, and how it affects your appeal rights.
• Medicare Advantage Plan Denied Your Claim
  Your Medicare Advantage plan denied your claim. Learn how MA plan denials differ from Original Medicare, your appeal rights, and why most appealed denials get overturned.
• Medicare Denied Ambulance Claim
  Medicare denied your ambulance transport claim. Learn why ambulance services get denied, when Medicare covers ambulance rides, and how to appeal the denial successfully.
• Medicare Denied Claim for Late Filing (Timely Filing)
  Medicare denied your claim because it was not submitted within the required time limit. Learn what timely filing means, your limited options, and whether you can still appeal.
• Medicare Denied Claim: Car Accident or Work Injury
  Medicare denied your claim because auto insurance or workers' comp should pay first. Learn about Medicare Secondary Payer rules for accidents and injuries and what to do.
• Medicare Denied Home Health Care Claim
  Medicare denied your home health care claim. Learn about the homebound requirement, skilled need rules, face-to-face encounter requirements, and how to appeal the denial.
• Medicare Denied Lab Work or Diagnostic Test
  Medicare denied your lab test or diagnostic test claim. Learn about coverage determinations, common reasons lab tests get denied, and how to appeal or resolve the denial.
• Medicare Denied Physical Therapy Claim
  Medicare denied your physical therapy, occupational therapy, or speech therapy claim. Learn about Jimmo v. Sebelius maintenance coverage, removed therapy caps, and how to appeal.
• Medicare Denied Prescription Drug (Part D)
  Medicare Part D denied coverage for your prescription drug. Learn about formulary exceptions, step therapy, prior authorization requirements, and how to appeal the denial.
• Medicare Denied Skilled Nursing Facility Stay
  Medicare denied your skilled nursing facility stay. Learn about the 3-day hospital rule, observation status, the 100-day benefit limit, and how to appeal the denial.
• Medicare Observation vs. Inpatient Status Denied
  Medicare denied your hospital stay because you were placed on observation instead of inpatient status. Learn about the 2-midnight rule, MOON notices, and how to appeal.
• Medicare Secondary Payer: Not Your Primary Plan
  Medicare denied your claim because another health plan should pay first, like employer coverage or COBRA. Learn about Medicare Secondary Payer rules and how to fix this.
• Medicare Sequestration: 2% Payment Reduction
  Your Medicare payment was reduced by 2% due to federal sequestration. Learn what sequestration means, why it happened, and why you should not be billed for the difference.