Read your Medicare Summary Notices

Medicare Summary Notices are Medicare’s explanations of coverage to a Medicare beneficiary.

After a Medicare beneficiary receives service from a Medicare provider or supplier, that provider or supplier notifies Medicare. Medicare then decides if the service is covered and how much coverage is available for that service. This determination is a coverage determination and it generates a Medicare Summary Notice. Medicare Summary Notices are mailed out quarterly.

Medicare Summary Notices contain lots of information about how or if Medicare covered a particular service or supply. Many dates of service may appear on the same Medicare Summary Notice so beneficiaries should go through each date of service to see how and if Medicare covered that service. A Medicare Summary Notice may contain information on both covered and uncovered claims. Importantly, it serves as a beneficiary’s first notice of how Medicare covered a particular item or service.

Beneficiaries who find services were not covered or not covered in the amount expected can appeal Medicare’s decision contained in the Medicare Summary Notice.

Important appeal rights attach to this first notice of Medicare’s coverage determination. There are deadlines for filing appeals of Medicare coverage determinations. For the first appeal, redetermination, beneficiaries must file the appeal within 120 days from the receipt of the Medicare Summary Notice.

The deadline begins to run as soon as a Medicare beneficiary receives the Medicare Summary Notice. Beneficiaries are presumed to have received the Medicare Summary Notice five days after the date on the Medicare Summary Notice. Appeal deadlines are calculated based on the date on the Medicare Summary Notice, not the date of the service.

Failure to appeal a Medicare coverage determination within the set deadline may prevent appealing at all, regardless of the merits of the appeal.

All Medicare beneficiaries should review their Medicare Summary Notices every time and for every service to make sure services and supplies are being covered correctly. If you need help understanding your Medicare Summary Notice, you can contact 1-800-Medicare or make an appointment with your local elderly benefits specialist. Benefit specialists are Medicare experts and can help with appeals as well as providing information about Medicare benefits and services.

If you have any additional questions, you may call Pat Hafermann, elderly benefits specialist with the Aging and Disability Resource Center, at (920) 459-4389.

Resource: “The Specialist” August 2009