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You have a right to appeal many decisions a Medicare Advantage Plan may make. Appealable decisions include the following types of decisions:

  • Failure to approve a treatment or medical procedure.
  • Failure to allow a referral to a specialist, either in or out of network.
  • Failure to pay charges for non-network medical care such as emergency care, urgently needed care, or care from a non-network provider you believed was or should be covered.
  • Attempting to discharge you from a hospital or terminate other medical treatment sooner than you believe to be medically appropriate.

The appeals process is the same, regardless of what is being appealed. A preferred method of starting an appeal is to call from your doctor's office. In any event, your doctor is your strongest ally in the appeal process.

For information about how to appeal, see:

NOTE: An appeal is different than a grievance. If you feel you have a grievance, such as poor service or rude behavior, file a grievance so other users will know. To learn more, click here.  (You can file both an appeal and a grievance if the situation warrants).

Rules The Plan Must Follow When Making A Denial

The denial of a service (or discontinuance of an ongoing treatment) must:

  • Be in writing.
  • State the reasons for the denial clearly and in terms that will allow you to argue your case.
  • List all appeal rights you have, including time limits.
  • Provide instructions on how to obtain evidence, including medical records and supporting affidavits from attending physicians.
  • Give you a timely response based on the seriousness of your medical condition.

The Appeals Process

The appeals process will be spelled out in the denial letter. It will also include dates by which appeals must be started. Do not assume you can appeal after the described date.

After the internal review process, you have the right to have a denial of reviewed by an independent body that contracts with Medicare.

If you do not receive satisfaction, you have the right to appeal to an Administrative Law Judge, and eventually to use the courts.

If you have difficulty that may be newsworthy, see: How To Involve The Press.

Two Types Of Appeal: Standard And Expedited

There are two types of appeals that you can make in response to the initial denial, the standard appeal and the expedited appeal.

The Standard Appeal

The standard appeal is the same as appealing the denial of treatment by a regular Medicare Advantage Plan. Check your Medicare Advantage Plan booklet of coverage and/or with the Plan's Member Services Department for any special requirements the Plan may have, as well as the address to which to send appeals.

The Expedited Appeal.

Because a Medicare Advantage Plan may deny a service before it has been provided, a provision is made for a more prompt appeal.

You have the right to an expedited appeal if the failure to receive the denied services quickly will either jeopardize your life or health or jeopardize your ability to regain your maximum function.

Expedited appeals are most often used with respect to medical issues such as the denial of a treatment or procedure recommended by your doctor or the determination to terminate or discontinue a treatment or procedure.

If the appeal is about a medical issue, your primary care doctor or specialist will be a primary ally.

A decision must be made on expedited appeals within 72 hours.

You can do an expedited appeal solely by telephone or solely through a letter.

A Preferred Method Of Making An Appeal

Consider making an appeal by calling from your doctor's office. You may get a "yes." At the least, you'll get a better understanding of why the Plan is saying "no." Immediately follow up the call with a letter.

A suggested scenario:

  • Work closely with your doctor before the call. Get your arguments in order.
  • Have the doctor available to get on the call to give his or her medical arguments directly. (You'll also get an opportunity to how strongly the doctor advocates for you).
  • Use the words "expedited appeal" when you call. For instance: "I'm calling to request an expedited appeal on your refusal to cover the MRI proposed by my doctor, Dr. Welby. I believe it should be covered because we still have not found what is causing my abdominal pains and cramps and an MRI seems to be the last diagnostic procedure. We need to rule out any type of cancer. As I understand it, an MRI is the only sure way to do it. May I put my doctor, Dr. Welby on the phone to explain it from a medical professional point of view?"
  • Keep a record of date, time, phone number(s), fax number(s), name(s) of people talked with, what was said, and what the next steps are.

After the initial phone call, fax written statements by yourself and your doctor via fax. This puts your arguments in writing and assures that your arguments will be passed on without change or editing. (It may help hone your and your doctor's arguments if you write the letter before the phone call. You can make last minute changes based on the phone call before faxing.) Call the Medicare Advantage Plan shortly after faxing the appeal letter to make sure it was received.