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In this blog post we discuss how to file an appeal with Original Medicare or your Medicare Advantage Plan.

What is an appeal?

An appeal is a formal request for review of a decision made by Original Medicare or your Medicare Advantage Plan. If you are denied coverage for a health service or item, you have the right to appeal the decision. Many times, filing an appeal can be a way of successfully covering a service that was previously denied.

Let’s understand what to do if you are denied coverage for a health care service or item.

Before you start your appeal, make sure you read all the letters and notices sent by Medicare or your plan. Call 1-800-MEDICARE or your private plan to learn why your coverage is being denied, if the reason was not provided or if you don’t understand it. This will help you address the reason for denial in your appeal letter. You can strengthen your appeal by including a letter of support from your doctor that explains why you need the service or item.

There is more than one level of appeal, and you have the right to continue appealing if you are not successful at the first level. Be aware that at each level there is a separate timeframe for when you must file the appeal and when you will receive a decision. Make sure to file each appeal in a timely manner, or your appeal may not be considered. If there is a reason you cannot submit your appeal within the timeframe, see whether you are eligible for a good cause extension. An appeal is different from a grievance, which is a formal complaint that you file with your plan. Grievances are discussed later in this blog.

For individualized, unbiased counseling and assistance regarding Medicare grievances, denials, and appeals, contact your State Health Insurance Assistance Program (SHIP). Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted). 

If you have Original Medicare, here is how you can begin an appeal.

To find out if Original Medicare has denied coverage for the health care services you have received, check your Medicare Summary Notice, or MSN. The MSN is a summary of health care services and items you have received during the previous three months. The MSN is not a bill. MSNs contain information about charges billed to Medicare, the amount that Medicare paid, and the amount you are responsible for. 

If your MSN says that Medicare did not pay for a service, and you think it should, call your doctor before appealing to make sure that there was not a billing error. Also look for the notes on your MSN that may explain the reason for denial. Then, start your appeal by following the appeal instructions listed on your MSN. Next, send your appeal to the Medicare Administrative Contractor, or MAC, within 120 days of the date on your MSN. The MAC’s name and address are listed in the shaded section of your MSN. The MAC 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 can move on to the next level by following the instructions on the MAC denial notice.

Remember that you can always contact your SHIP for individualized counseling and assistance regarding Medicare denials and appeals. Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted).  

If you have a Medicare Advantage Plan, here is how you can begin a pre-service appeal.

If your plan denies coverage for a health service or item before you receive it (such as durable medical equipment or a skilled nursing facility stay), you can appeal to ask the plan to reconsider its decision. Before you start your appeal, you will need to get an official written decision from your plan, called a Notice of Denial of Medical Coverage. You can start your appeal by following the instructions on the Notice of Denial of Medical Coverage and filing 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. Your plan should make a decision within 30 days.

This process looks a little different if your Medicare Advantage Plan denies coverage for a service or item that you have already received.

You should receive a written notice from your plan stating that it is not covering your health service or item. This can either be an Explanation of Benefits, called an EOB, or a Notice of Denial of Payment. This is not a bill. Start your appeal by following the instructions on the notice you received from your plan, and file the appeal within 60 days of the date on the notice. 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 can move on to further levels of appeal by following instructions on the denial notice.

When to file a grievance with your plan instead of an appeal.

If you are dissatisfied with your Medicare Advantage or Part D prescription drug plan for any reason, you can choose to file a grievance. A grievance is a formal complaint that you file with your plan. It is not an appeal. Times, when you may wish to file a grievance, include if your plan has poor customer service or you face administrative problems (such as the plan taking too long to file your appeal or failing to deliver a promised refund). In some cases, you may want to file both an appeal and a grievance. To file a grievance, send a letter to your plan’s Grievance and Appeals department within 60 days of the event that led to the grievance. Check your plan’s website or contact them by phone for the address. Your plan must investigate your grievance and get back to you within 30 days. If you have not heard back from your plan within this time, you can check the status of your grievance by calling your plan or 1-800-MEDICARE.

Still have questions?  

Your SHIP is here for you! You can contact your SHIP for questions regarding your grievance, denial, or appeal. SHIP counselors are government-funded to provide trusted, unbiased Medicare counseling at no cost to you. (Depending on your state, your SHIP may go by another name.)  

Use our online SHIP Locator or call 877-839-2675 (and say “Medicare” when prompted).