Appeals & Problems

• Medicare denied a service. Can I appeal?Yes. The first level for Original Medicare is a Redetermination filed with the Medicare Administrative Contractor (MAC) within 120 days of the denial notice (MSN).
• TFL denied a claim. How do I appeal?WPS handles TFL appeals. File a written reconsideration with WPS within 90 days of the denial. Include the Medicare EOB, the WPS denial, and any supporting medical records.
• What do I do if my Medicare claim is denied?Read the MSN denial reason, gather supporting records, and file a Redetermination with the Medicare Administrative Contractor within 120 days.
• Do I appeal to Medicare or to TFL?Appeal to whichever payer issued the denial. If Medicare denied, appeal Medicare. If WPS denied TFL's share, appeal to WPS.
• Can I get a faster appeal for urgent care?Yes. Both Medicare Advantage and Original Medicare allow expedited appeals when delay could jeopardize your health. Decisions come in 72 hours.
• A doctor is balance-billing me. Is that legal?Medicare-participating providers cannot balance bill. Non-participating providers can charge up to the limiting charge. Opt-out providers can bill anything. Identify the type before paying.
• I see services on my MSN I never received. What do I do?It could be a coding error or fraud. Call the provider first; if unresolved, report to 1-800-MEDICARE and the OIG Hotline.
• Where can I get free help understanding a denial or bill?Your State Health Insurance Assistance Program (SHIP) provides free, unbiased one-on-one counseling. Find your local SHIP at shiphelp.org.

Educational only — not insurance, legal, or tax advice. Verify with Medicare (1-800-MEDICARE), WPS (1-866-773-0404), SSA, or a licensed advisor before making enrollment decisions.