Make sure you read your Medicare notices. They include important information, such as why your care was denied and how you can appeal.
Appealing a Medicare coverage decision should be done promptly, as each level of appeal has a set timeframe to file.
A letter of support and documentation from a doctor can help you create a strong appeal.
If you were denied coverage for a health service or item by Medicare, you have the right to appeal the decision. There is more than one level of appeal, and you can continue appealing if you are not successful at first. Be aware that at each level there is a separate timeframe for when you must file the appeal.
How do I know if I’ve received a Medicare denial?
If you have Original Medicare, you should receive Medicare Summary Notices (MSNs). If you have a Medicare Advantage Plan, you should receive Explanation of Benefits (EOBs). Both MSNs and EOBs are summaries of the care you received during a timeframe, how much the provider billed, the amount your insurance will pay, and how much you may owe the provider. If you are denied a medical service or item, it should be listed on your MSN or EOB, along with a reason for the denial.
TIP: Understanding the reason for denial is important to your appeal. If you are confused about the reason for denial, you should call 1-800-MEDICARE (if you have Original Medicare) or your Medicare Advantage Plan to learn more about the denial.
How do I start an appeal for a denial from Original Medicare?
Start your appeal by following the appeal instructions listed on your Medicare Summary Notice (MSN). This includes circling the denied service listed and filling out the shaded section at the end of the MSN. Then, send your appeal to the Medicare Administrative Contractor (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.) This will start your appeal. The MAC should make a decision within 60 days. If the appeal is successful, the service or item will be covered.
How do I start an appeal for a denial from my Medicare Advantage Plan?
First, begin by ensuring you have a written denial notice. If you do not yet have one, you can contact your plan.
- If you have already received the care that is being denied, you should have the denial on your EOB. An appeal of this decision is called a post-service appeal.
- If the denial is for a service or item that you have not yet received, you should get a Notice of Denial of Medical Coverage from your plan. An appeal of this decision is called a pre-service appeal.
Start the appeal by following the instructions on the notice. The appeal should be filed within 60 days of the date on the notice and will most likely require you to send a letter to the plan, explaining why the care is/was needed. You should ask your doctor for help with this letter.
- For a post-service appeal, your plan should make its decision within 60 days.
- For a pre-service appeal, the plan should decide within 30 days.
TIP: If you are filing a pre-service appeal (meaning you were denied coverage for an item or service that you have not yet received), you can request an expedited appeal if the matter is urgent. An appeal can be expedited if you or your doctor feels 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.
What can I do if my first appeal is denied?
If your appeal is denied at the first level, you have the right to continue appealing! Individuals whose appeals are at first denied, may find their appeals are successful at later stages of the process. Instructions for how to file your next appeal will be on the notice of denial you receive. Remember that each level has its own timeframe for when you must file an appeal and when you should receive a decision, so ensure you are filing in a timely manner.
TIP: In later levels of appeal (such as if your appeal is with the Office of Medicare Hearings and Appeals [OMHA], the Council, or the Federal District Court), you may wish to consult a lawyer for assistance. While it is not required that you have representation, these later levels of appeal can be more complex, and expert assistance can be useful.
See the infographic below for an illustration of the appeals process.
Can I still file a Medicare coverage denial appeal if I miss a deadline?
If you can show good cause for not filing on time, your late appeal may still be considered. You can request a good cause extension at any level of appeal and whether you have Original Medicare or a Medicare Advantage Plan. You can request a good cause extension just by sending in your appeal as you normally would and including a clear explanation of why the appeal is late. Extensions are considered on a case-by-case basis, so there is no complete list of acceptable reasons for filing a late appeal, but some examples may include:
- The notice being appealed was mailed to the wrong address.
- Illness (either yours or a close family member’s) prevented you from handling business matters.
- A Medicare representative gave you incorrect information about the claim being appealed.
TIP: If the reason has to do with illness or other medical conditions, including a letter or supporting documentation from your doctor can be helpful.
Can someone file a Medicare coverage denial appeal on my behalf?
Yes! You can appoint a representative to appeal a denial on your behalf. To appoint a representative, complete the Appointment of Representative form and mail it to either your MAC (if you have Original Medicare) or your Medicare Advantage Plan. Alternatively, rather than complete this form, you can submit a written request alongside your appeal. The written request should include:
- Your name, address, phone number, and Medicare number
- A statement appointing someone as your representative
- The name, address, and phone number of the representative
- Your relationship to the representative
- A statement authorizing the release of your personal and health information to the representative
- A statement explaining why you are being represented and to what extent
TIP: Your representative can be anyone willing to act on your behalf, such as a friend, family member, social worker, doctor, or lawyer.
How can I strengthen my appeal?
Make sure your appeal is as strong as possible to increase your chances of successfully overturning the denial. Here are some tips that can help you during the appeal process:
- Read all relevant notices carefully and reach out for help if you do not understand your denial notices.
- Make sure to meet your appeal deadlines, or to request a good cause extension if you cannot.
- Include a letter or supporting documentation from your doctor with the appeal.
- Keep a copy of all documents you send and receive.
- If possible, send the appeal with certified mail or delivery confirmation.
- Do not send the original copies of important documents.
- Write down the names of any representatives you speak with, the date and time of your conversation, and what you discussed.
In summary, if you are denied coverage for a medical service or item, you have the right to file an appeal. Your denial notice (whether it’s your MSN, EOB, or Notice of Denial of Medical Coverage) will provide lots of helpful information, such as why your care was denied, where to send your appeal, and how many days you have to file your appeal. To really strengthen your appeal, you should include a letter or supporting documentation from your doctor, explaining why this care is medically necessary for you. If your appeal is unsuccessful at the first level, keep going!
Download the fact sheet below to keep this information handy.