Medicare Advantage: Claims: Appeals

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.

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