Medicare Advantage Denials Process


Often times, patients eligible for Medicare benefits choose to insure themselves or their loved ones through a private insurance agency called a Medicare Managed Care Advantage (often referred to as “MA”) program. Many of these plans have the ability to determine you or your loved ones eligibility to receive certain medically-necessary benefits to control cost and limit your choices when it comes to your care options, including inpatient rehabilitation. The information provided on this page in intended to give patients background information and provide guidance to the denial process that can be experienced by some Medicare Advantage beneficiaries seeking care at Northeast Rehabilitation.

Why would my claim be denied?

There are many reasons why Medicare Advantage may deny a claim for inpatient rehabilitation. A few examples include:

  • Concluding that you or your loved one’s healthcare needs could effectively be managed at a lower level of care, such as a skilled nursing facility.
  • Requesting “more information” about your or your loved one’s case so that authorization for the inpatient rehab stay is delayed.
  • Citing “insufficient documentation” from the referring providers notes regarding your care and the prognosis for recovery.
  • Concluding that you or your loved one is “too sick” or “not sick enough” to qualify for inpatient rehabilitation level of care.

If my claim is denied, does Northeast Rehab try to appeal that decision?

Absolutely! If our Managed Care Specialist disagrees with the Medicare Advantage findings, and believes that you or your loved one are still a candidate for inpatient rehabilitation, we will work with the referring hospital to follow all the necessary steps required to make a formal appeal. This can be a time consuming and lengthy process, and we may ask for you or your families help in getting the necessary paperwork filed.

Is there anything I can do to get my claim appealed quicker?

Yes! We encourage patients and families to be available to provide paperwork and help us with the appeal process. The Managed Care Specialist at Northeast Rehab may call you or your loved one to assist in filing a “Patient Reconsideration Request”. Throughout the appeal process, our Managed Care Specialist will keep you informed of the progress of the application.

Who do I contact if I have any questions regarding my claim or appeal?

Northeast Rehabilitation has a Managed Care Specialist on site M-F during regular business hours. Please call 603-681-3034 to speak to a Specialist today. Messages left on the voicemail during off-hours is confidential and your call will be returned during regular business hours.