You received treatment that Medicare says it doesn't cover

When a doctor or hospital bills you for treatment Medicare won't pay for, you have specific rights and steps to take. The first thing to know is that you may not owe the full bill — it depends on whether your provider knew in advance that Medicare wouldn't cover it, and whether they told you.

Medicare has rules about what it will and won't pay for. Some treatments are not covered at all. Some are covered only under certain conditions — for example, only if you meet specific medical criteria, or only in a hospital rather than an outpatient clinic. When treatment falls outside these rules, the provider cannot automatically charge you the full cost. The law requires them to notify you in writing before the service happens, so you can decide whether to go ahead.

Key Takeaways

  • If you received an uncovered service without a written notice beforehand, you may not owe anything — the provider may have to absorb the cost.
  • A proper notice is called an Advance Beneficiary Notice of Noncoverage (ABN), and it must be signed by you before the service takes place.
  • If you signed an ABN, you agreed to pay if Medicare denied coverage, but you can still dispute whether the service was truly not covered.
  • You have the right to see what Medicare decided about your claim and to challenge that decision through an appeal.
  • Contact your Medicare plan or Medicare directly to request a copy of the coverage decision and learn how to file an appeal.

What an Advance Beneficiary Notice should have said

Before a provider gives you a service they think Medicare won't cover, they must give you a form called an Advance Beneficiary Notice of Noncoverage (ABN). This is a specific document — not just a verbal warning or a note buried in paperwork. The ABN must be on the official CMS form (Form CMS-R-131), and it must be signed and dated by you before the service happens.

The ABN tells you three things: what service you are about to receive, why the provider believes Medicare won't cover it, and that you will be responsible for the cost if Medicare says no. It also gives you the choice to receive the service anyway and pay out of pocket, or to skip it. If you did not receive a separate, signed ABN before the service, the provider cannot legally bill you for an uncovered service.

If you received treatment and now have a bill you do not think you should owe, your first step is to check whether an ABN was actually signed. Look through the paperwork you received at the time of service. If there is no ABN, or if it was signed after the service took place, you have a strong argument that you should not owe the bill.

How to find out what Medicare actually decided

You need to see the official coverage decision from Medicare. This is not the same as the bill from your provider. Medicare makes its own information about whether a service is covered, and that information is separate from what you owe.

If you have Original Medicare (Parts A and B), contact Medicare directly at 1-800-MEDICARE (1-800-633-4227) and ask for a copy of the Explanation of Benefits (EOB) for the date of service. The EOB shows what Medicare was billed, what it decided to cover or deny, and why. If you have a Medicare Advantage plan (Part C), contact your plan directly and ask for the same information.

The EOB will tell you whether Medicare denied the claim because the service is not covered under any circumstances, or because it was not covered in your specific case (for example, because you did not meet medical necessity criteria, or because you had already used your benefit limit). This distinction matters for your appeal.

When you signed an ABN but think the service should have been covered

If you did sign an ABN, you agreed that you would pay if Medicare denied coverage. However, signing an ABN does not mean you have no recourse. You can still challenge whether Medicare's decision was correct — that is, whether the service truly falls outside Medicare coverage rules.

This is done through an appeal. You are asking Medicare to reconsider its decision, not asking to be released from the bill you agreed to pay. To appeal, you need the EOB showing Medicare's denial, and you may want to gather medical records or a letter from your doctor explaining why the service was medically necessary. You have 120 days from the date on the EOB to file an appeal.

For Original Medicare, file your appeal with Medicare directly using the instructions on the EOB. For a Medicare Advantage plan, file with your plan. The first level of appeal is called a reconsideration, and it is reviewed by someone who did not make the original decision.

If you did not sign an ABN and received a bill

If there is no signed ABN in your records, write to the provider in writing and state that you did not receive proper notice before the service. Keep a copy of your letter. Ask them to either remove the bill or provide the signed ABN. Give them 30 days to respond.

If they do not respond or refuse, you can file a complaint with your state's health department or your state's insurance commissioner. You can also contact your Medicare plan or Medicare directly and report that you received an uncovered service without proper notice. Medicare has the authority to investigate whether the provider violated the ABN rules.

Do not ignore a bill or assume you have to pay it. Providers sometimes bill patients for uncovered services as a routine practice, counting on the fact that many people will pay rather than question it. If the paperwork is not in order, you have the right to challenge the charge.

What happens if you already paid

If you have already paid a bill for an uncovered service, you may be able to get a refund. This depends on whether the provider should have given you an ABN and whether they can show you signed one.

Start by requesting a refund in writing from the provider's billing department. Explain that you did not receive a proper Advance Beneficiary Notice before the service. Keep copies of everything you send. If the provider refuses or does not respond within 30 days, file a complaint with your state's health department.

You can also ask Medicare or your Medicare Advantage plan to investigate. If they determine that the provider violated the ABN rules, they can require the provider to refund you. This process takes time, but it is worth pursuing if the bill was substantial.

Understanding the difference between "not covered" and "not medically necessary"

Medicare denies claims for two different reasons, and they matter for your appeal. A service can be not covered — meaning Medicare straightforward does not pay for it under any circumstances, like cosmetic surgery or most dental work. Or it can be covered in general, but not in your case — meaning Medicare pays for the service, but your doctor did not document that you met the medical criteria, or you had already used your limit.

If Medicare says the service is not covered at all, your appeal is harder to win — you are asking Medicare to change its coverage policy, which rarely happens. If Medicare says it is covered but was not medically necessary in your case, your appeal is stronger — you can provide medical records and a doctor's statement showing that it was necessary.

The EOB will specify which reason Medicare gave. If it is unclear, call Medicare or your plan and ask them to explain the denial in plain language.

Frequently Asked Questions

Can a provider bill me for a service if I verbally agreed to pay?

No. Verbal agreement is not enough. The law requires a signed, written Advance Beneficiary Notice on the official CMS form. A verbal warning, an email, or a note in your paperwork does not meet the legal requirement. If you were not given a separate, signed ABN before the service, the provider cannot legally bill you.

What if the provider says the ABN was in the packet of forms I signed?

If the ABN was mixed in with other forms and you did not sign it separately, it may not be valid. The ABN must be a distinct document that you sign specifically acknowledging that you understand the service is not covered. Look at what you actually signed. If you cannot find a separate ABN signature, you have grounds to dispute the bill.

How long does a Medicare appeal take?

A reconsideration (the first level of appeal) usually takes 30 to 60 days. If you disagree with that decision, you can request a hearing before an administrative law judge, which can take several months. During this time, you are not required to pay the bill while the appeal is pending, though the provider may continue to send statements.

What if my Medicare Advantage plan says a service is not covered?

Medicare Advantage plans can have different coverage rules than Original Medicare. If your plan denies coverage, ask for the specific reason in writing. You have the right to appeal within your plan, and if you disagree with the plan's decision, you can file a complaint with your state's insurance commissioner or with Medicare.

Do I need a lawyer to appeal?

No. You can file an appeal on your own by following the instructions on your EOB. However, if the bill is large or the case is complex, you may want to consult with a patient advocate or an attorney who handles Medicare disputes. Some will work on a contingency basis if you win your appeal.