Sample Agreement
Medicare will only pay for services that it determines
to be reasonable and necessary under section 1862(a)(1)
of the Medicare law.
If Medicare determines that a particular service, although
it would otherwise be covered, is "not reasonable and
necessary" under Medicare program standards, Medicare
will deny payment for that service.
-
I believe that, in your case, Medicare may deny payment
for Diagnosis:
-
Procedure:
-
Because: (reason for denial)
I have been notified by my physician that he or she believes
that, in my case, Medicare may deny payment for the service(s)
identified above, for the reason(s) stated. If Medicare
denies payment, I agree to be personally and fully responsible
for payment.
SIGNED:______________________________________________
DATE:________________________________________________
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