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How do I appeal a pre-service denial from my Medicare Advantage Plan?

If your Medicare Advantage Plan denies coverage for a health service or item before you have received the service or item, you can appeal to ask your plan to reconsider its decision. Follow the steps below if you feel that the denied health service or item should be covered by your plan. You can also view this chart for a brief outline of the Medicare Advantage appeal process.


•            Before you can start your appeal, you will need to get an official written decision from your plan, called a Notice of Denial of Medical Coverage. Sometimes you first learn that your plan will not cover a service or item when you or your doctor calls to confirm coverage before the service is provided. If the plan tells you that the service or item will not be covered, they should also send you a Notice of Denial of Medicare Coverage. You should receive this written denial within 14 days.


o            If you don’t receive a Notice of Denial of Medicare Coverage within two weeks (or 28 days if your plan extended its decision deadline), you can file an appeal without it. Start your appeal by sending a letter to your plan explaining that it has been two weeks since you initially requested an item or service, and you have not received a denial notice. If possible, include a doctor’s letter of support. You may also want to file a grievance.


•            You can request a fast (expedited) appeal if you or your doctor feel that your health could be seriously harmed by waiting the standard timeline for appeal decisions. If your plan approves your request to expedite, it should issue a decision within 72 hours. For this and the following levels of appeal, your doctor can ask that the plan follow the expedited timeline.

o            In some cases, your plan can extend its decision deadline up to 14 days. You should be notified if this happens.


•            Start your appeal by following the instructions on the Notice of Denial of Medical Coverage. Make sure to file your appeal within 60 days of the date on this notice. You will need to send a letter to your plan explaining why you need the service or item. 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. Your plan should make a decision within 30 days. If you file an expedited appeal, your plan should make a decision within 72 hours.


o            If you have a good reason for missing your appeal deadline, you may be eligible for a good cause extension.


•            If the appeal is successful, your service or item will be covered. If you appeal is denied, you should receive a written denial notice. Your plan should also automatically forward your appeal to the next level, the Independent Review Entity (IRE). There are several further steps in the appeals process that you may follow if your appeal continues to be denied.


Remember to keep good records of all your communications throughout the appeals process. You should submit all requests in writing, and keep fax transmission reports, mail information by certified mail, or return receipts. Write down the details of any phone calls you make related to your case, including what you discussed, who you spoke to, and the date and time of the call.


If you need assistance understanding the coverage rules surrounding a health service or item, or help completing your appeal, you can contact your State Health Insurance Assistance Program (SHIP) for assistance by calling 877-839-2675.



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Posted June 21, 2021 by at United States in Medicare
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