How to Appeal a Medicare Advantage Denial

Step by step: how to file your appeal

1. Find your denial notice and mark the date.

   Your plan sends a written notice when it denies coverage or payment. Look for the date printed on it, then count 65 days forward and write that date on your calendar. The notice also tells you where and how to send your appeal.

2. Decide whether you need a fast appeal.

   If you are waiting on care and the standard time could seriously harm your life, your health, or your ability to get back to full function, ask for an expedited appeal. A fast request can be made by phone or in writing. Ask your doctor to say in writing that waiting is not safe.

3. Find the exact reason for the denial.

   Read the reason word for word. Did the plan say the care was not medically necessary, that it needed prior approval, or that a different treatment should be tried first? Your appeal should answer that exact reason. You can call the plan and ask which guideline or rule it used.

4. Gather your proof.

   Collect the office notes, test results, imaging reports, and a list of treatments you already tried. Ask your doctor for a short letter explaining why you need this care now. A doctor's letter that speaks directly to the plan's reason is often the most important page you send.

5. Write your reconsideration request.

   Include your name, your plan member number, the service or item that was denied, the date of the notice, and a clear statement that you are asking for a reconsideration. Explain in plain words why the care is needed, and list each document you are attaching. The free AppealRN builder walks you through this and writes the letter for you.

6. Send it the way your notice says and keep proof.

   Use the address, fax number, or portal listed on your notice. Keep a copy of everything you send. If you mail it, use a method that shows the date it was delivered. Write down the date, time, and name of anyone you speak with at the plan.

7. Watch for the plan's decision.

   The plan has 30 days to decide a request about a service, 60 days for a payment, and 7 days for a Part B drug. If it agrees with you, it must cover the care or pay the claim.

8. If the answer is still no, know what comes next.

   When the plan upholds its denial in whole or in part, it must forward your case to the Independent Review Entity automatically. You do not have to file anything for this second level. If the reviewer also says no, you can ask for a hearing with an Administrative Law Judge within 60 days of receiving that decision, as long as the amount in dispute meets that year's minimum.

The five levels of Medicare Advantage appeals

Most people only need the first level or two, but it helps to see the whole path.

1. Reconsideration by your plan

   Request within 65 days of the denial notice.

2. Review by the Independent Review Entity

   Your plan sends your case here automatically if it keeps the denial.

3. Hearing with the Office of Medicare Hearings and Appeals

   An Administrative Law Judge hears your case. Request it within 60 days of the second level decision if the amount meets the yearly minimum.

4. Review by the Medicare Appeals Council

   Request within 60 days after you get the hearing decision.

5. Judicial review in federal district court

   The final level, for cases that meet the required amount.

What makes a reconsideration request stronger

Can someone file for you?

Yes. You, your doctor, or a representative you choose can ask for the reconsideration. If a family member or friend is helping, fill out the Appointment of Representative form, CMS 1696, and send it with the appeal so the plan will talk with them.

Is this the right process for you?

This page is for Medicare Advantage plans, sometimes called Part C. If you have Original Medicare, your first appeal is a redetermination, and you have 120 days after you receive your Medicare Summary Notice. Prescription drug denials under a Part D plan follow their own steps, so follow the instructions on that notice. See our appeal deadlines by plan type for a side by side view.

Frequently asked questions

Keep reading

Sources

• Medicare.gov: Appeals in Medicare health plans
• CMS: Reconsideration by the Medicare Advantage, Part C, health plan
• CMS: Medicare managed care appeals and grievances
• CMS: Appointment of Representative form CMS 1696