Content created by Office of Medicare Hearings and Appeals (OMHA)
Step 1. Your doctor or hospital submits a bill to Medicare.
Medicare contracts with private companies ("contractors") to process medical claims (bills) for health care items and services provided to Medicare beneficiaries.
Step 2. A determination is made on how much Medicare will pay.
After a claim is sent to the appropriate contractor, the contractor must:
- Determine if the items and services on the claim are covered or reimbursable by Medicare;
- Calculate any amount that is payable by Medicare;
- Make the payments to health care provider(s) who furnished the items or services; and
- Notify you of its decision to pay or deny coverage or payment for specific items or services.
Step 3. If you disagree with the Medicare contractor's decision on your claim, you have the right to file an appeal. The first level of an appeal for Original Medicare is called a redetermination. A redetermination is performed by the same contractor that processed your Medicare claim. However, the individual that performs the appeal is not the same individual that processed your claim. The appeal is a new and independent review of your claim.