Medicare Advantage: Claims: Appeals

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:

• Rules The Plan Must Follow When Making A Denial  
• The Appeals Process  
  
• Two Types Of Appeal: Standard And Expedited  
  
• A Preferred Method Of Making An Appeal
  
• General Rules For When You Have Contact With An Insurer, Employer Or Government Agency
  

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).

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