Medicare Advantage appeal checklist

Identify the decision

• Confirm the decision came from a Medicare Advantage plan.
• Identify whether it concerns a requested service, item, Part B drug, prior authorization, continued care, or payment.
• Separate a Part D drug decision, Original Medicare claim, or service-termination notice that uses another appeal route.
• Save every page of the organization determination notice.

Protect the filing deadline

• Record the date printed on the denial notice.
• Calculate the plan's stated filing period and aim to submit well before it expires.
• If filing late, prepare a written explanation of the circumstances supporting good cause.
• Use the appeal destination in the notice or Evidence of Coverage.

Decide whether to request a fast appeal

• Ask whether waiting 30 days, or the applicable standard period, could seriously jeopardize life, health, or the ability to regain maximum function.
• Ask the physician to support the expedited request when medically appropriate.
• Use an oral or written expedited channel accepted by the plan.
• For a payment request after care was received, expect the standard payment route unless the plan directs otherwise.

Prepare the appeal record

• Name and Medicare number of the enrollee.
• Item, service, Part B drug, or payment being disputed.
• Dates of service or proposed service.
• Copy of the denial notice and relevant plan criteria.
• Short statement explaining the disagreement.
• Physician letter, medical records, treatment history, or other supporting evidence.
• Appointment-of-representative documentation when another person files.

Submit and document receipt

• Send the request to the plan, not CMS headquarters.
• Keep a copy of the complete submission.
• Save a portal receipt, fax report, certified-mail record, or confirmation number.
• Record the date and time of any oral expedited request and the name or reference number provided.
• Use secure channels for Medicare numbers and medical information.

Track the outcome

• Mark the applicable 72-hour, 7-day, 30-day, or 60-day response period.
• Read any notice of a 14-day extension and why the plan says it is needed.
• If approved, confirm authorization, scheduling, provision, or payment.
• If denied in whole or in part, keep the plan decision and watch for automatic level 2 review by the Part C Independent Review Entity.
• Follow the next notice rather than reusing the level 1 address.

Official sources

• Medicare.gov — Medicare health plan appeals
• CMS — health plan reconsideration
• CMS — Medicare Advantage notices and forms

Related resources

• Medicare Advantage appeal procedure
• Fast Medicare Advantage appeal
• Organization determination
• Centers for Medicare & Medicaid Services
• Hospital discharge appeal checklist