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How can I appeal a denial from a Medicare Advantage Plan?

If you have a Medicare Advantage Plan and were denied coverage for a health service or item that you have already received, you may choose to appeal to ask your plan to reconsider its decision. Follow the steps below if you think the denied health service or item should be covered by your plan.
 
First, start by reading your denial notice closely. It should explain what you need to do to appeal and the reason your care is not being covered. If you do not understand the reason for denial, you should call your plan directly to request more information. Understanding the basis for the denial will really help you in writing your appeal!
Start your appeal by following the instructions on the notice you received from your plan. Make sure to file your appeal within 60 days of the date on the notice (If you have a good reason for missing your appeal deadline, you may be eligible for a good cause extension). You will most likely need to send a letter to the plan explaining why you needed the service you received. You may also want to ask your doctor to write a letter of support, explaining why you need care and addressing the plan’s reason for denial. Make sure to keep copies of all the documents you received and sent during this process.  

Your plan should make a decision within 60 days. If your appeal is successful, your service or item will be covered. If your appeal is denied, you should receive a written denial notice. If your appeal is denied, the plan should automatically forward your appeal to the next level, the Independent Review Entity (IRE). You can read about the following levels of appeal here.

Note that you will follow different appeal processes if your plan has denied coverage for care you have not yet received or a prescription drug. Please see this chart for a brief outline of the Medicare Advantage appeal process.

If you need further assistance and counseling around your appeal, I recommend contacting your local State Health Insurance Assistance Program (SHIP). You can locate your SHIP by visiting www.shiphelp.org or calling 877-839-2675.
 
Best of luck!

-Marci

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Posted July 19, 2021 by at United States in Medicare
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