denial of coverage

What is denial of coverage?

Denial of coverage refers to a situation in which Original Medicare, a Medicare Advantage plan, or a Medicare Part D drug plan refuses to cover certain medical services.

What causes a Medicare denial of coverage?

A Medicare denial of coverage could be due to various factors. If you have Original Medicare, a denial of service could be due to:

• Medicare determines that the service is not medically necessary.
• You’re receiving routine dental or vision care, which are not covered by Original Medicare.
• You’ve run out of inpatient coverage days in your benefit period, or you’ve reached 100 days in a skilled nursing facility.
• You’ve entered a skilled nursing facility without a preceding inpatient hospital stay that lasted at least three days.¹
• You’re receiving custodial care (assistance with activities of daily living) without receiving skilled medical care at the same time.²

If you have Original Medicare or a Medicare Part D plan, additional reasons for coverage denials could include:

• You’re seeking care outside your plan’s provider network.
• You’ve been prescribed a medication that isn’t on your plan’s formulary (covered drug list).
• The plan requires prior authorization and you haven’t obtained it.