Inside Medicare | My Medicare claims are denied b/c my coverage shows that I have other insurance

Janell Sluga Medicare & Individual Health Insurance Account Executive View Bio

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Question:

I am new to Medicare, and I just retired. I enrolled in an insurance plan, but I am having a problem with my claims being processed. They are denying my coverage saying I have other insurance. What should I do?

Answer:

Many individuals work beyond 65. You might have become eligible for Medicare at age 65, but if you continue to work, you probably don’t need to sign up for Medicare. Once you decide to retire, you can sign up for Medicare at that time. There are rules regarding when to enroll in Medicare and who needs to do so and when you are working beyond age 65. Rather than discussing those rules today, let’s focus on your denied claims, which sound to me like a Coordination of Benefits issue.

Once you retire, you usually leave the health insurance plan that you had when you were working. Ideally, sometime before your retirement date and if you are over 65, you’ve researched and completed the Medicare enrollment process. This enrollment process usually goes smoothly. But sometimes the post-retirement insurance process gets a little bumpy.

Medicare does not always receive notice that your employer coverage has ended. Therefore, their records indicate you still have that employer coverage. This means when claims are sent to Medicare or the Medicare Advantage Plan you have, those claims are denied because they mistakenly believe that you have “other” coverage.

Sometimes these claims and their denial take some time to get to you. So, you find out weeks or months down the road that a claim was denied. This can be very frightening and frustrating. Especially because you probably have been paying for this new insurance and assumed that you did everything correctly – but now you are doubting yourself and the process.

The best way to resolve this issue is to reach out to Medicare (and your Medicare Advantage Plan if you enrolled into one) and inform them of your situation. You can do this by calling Medicare at 1-800-MEDICARE (633-4227) or the Coordination of Benefits Department of Medicare at 855-798-2627. To contact your Medicare Advantage Plan, find plan’s health insurance card, and call the customer service phone number listed on the back of the card. During this call, you can inform them of your retirement date, and tell them that your insurance with that employer has ended, including the actual end date. Usually, this attestation of the situation is enough to resolve the issue.

There are times when you must provide proof of termination for your former employer’s plan. In this situation, you can go to your previous employer and ask them to give you proof of your coverage, start to finish. This usually comes in the form of a letter stating when your employment began with the company, when the insurance began with that company, and when the employment and the insurance coverage ended.

This process is usually completed when you enrolled into Medicare because you had to complete two forms to get your Medicare started. First, you would have completed the 18-f-5 or 40B, which you completed yourself to request that your Medicare Part A & B or just your Medicare Part B (because you already have Medicare Part A) needs to begin. The second form that was completed is the L564, which was completed by your employer and includes the information I just stated, your employment start date, insurance start date, your employment end date, and the insurance end date.

However, sometimes even when these forms have been completed and turned into Social Security Administration prior to or just after your retirement, the information is not communicated completely, and this can cause these problems with your claims.

I believe that taking these steps will resolve your denied claims issue. Once you have updated your information with Medicare and your insurance company, you can contact your providers who had those denied claims and ask them to resubmit the claims. These claims can be reprocessed and paid as they should be.

Next week I will be covering how this process and rules are different with regard to Medicare Part D and Prescription Drug coverage. I always encourage individuals to reach out to for help including a call directly to Medicare, to your health insurance company, and to professionals in the field.

Send me your questions and concerns, together we can answer them for everyone! Medicare is wonderful insurance coverage, but the process is complicated and it sometimes has difficulties. We can work together to resolve them!

Janell Sluga is a Geriatric Care Manager helping seniors in our community access services and insurance. To reach her, please email jsluga@lawleyinsurance.com.