Steps for Appealing a Medicare Decision

What you need to know

If you disagree with a coverage or payment decision made by Medicare or your Medicare Advantage plan you have the option to file an appeal. You can file an appeal if you are denied one of the following:

• Your request for a health care service, supply, item or prescription that you think you should be able to get.
• Your request for payment for health care service, supply, item or a prescription drug you already got.
• Your request to change the amount you must pay for a health care service, supply, item, or prescription drug.

You can also appeal if Medicare or your Advantage plan stops providing or paying for all or part of an item or service you think you still need.

Where to begin?

If you are thinking about filing an appeal, talk to your doctor, health care provider or supplier. Ask them to provide any information that will support your appeal. Read your plan materials or contact your insurance agent or plan for details about your appeal rights. Medicare and all companies that provide Medicare Advantage plans are required to help you file an appeal.

The appeals process has 5 levels. If you disagree with the decision made at any level of the process, you can generally go to the next level. At each level, you'll be given instructions in the decision letter on how to move to the next level of appeal.

You have the right to appoint a representative to help you file an appeal.
 

Your representative can be your insurance agent, a family member, friend, attorney or doctor or anyone you choose to act on your behalf. One of the many benefits of having an insurance agent is having someone to act as your advocate. Your insurance agent knows you, your plan and the process for filing an appeal and provides this service at no additional charge.

If you have questions about any part of the appeal process, call 1-800-MEDICARE ((1-800-633-4227) or go to http://www.medicare.gov for more information.