Appeal a Medicare Advantage plan decision

Use the appeal route that matches the decision

This procedure covers medical items, services, payment decisions, and Medicare Part B drugs handled by a Medicare Advantage plan. A Part D prescription-drug decision, an Original Medicare claim, or a fast appeal about certain services that are ending uses a different process.

1. Confirm that you received an organization determination

An organization determination is the Medicare Advantage plan's initial decision about whether it will authorize, provide, or pay for an item or service. It can include a prior-authorization denial, a refusal to continue a service, a payment decision, or a decision involving a Part B drug. A complaint about customer service or quality of care is generally a grievance, not this appeal.

2. Read the denial notice and identify the deadline

The notice should explain what the plan denied, why it denied the request, how to appeal, and where to send the appeal. Current Medicare and CMS instructions use a filing period of 65 calendar days from the date on the initial denial notice. If you file after that period, explain why the request is late and ask the plan to find good cause.

Do not assume every Medicare notice has the same deadline. A notice that covered hospital, skilled nursing, home health, comprehensive outpatient rehabilitation, or hospice services are ending may contain a shorter deadline for an immediate review by a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO).

3. Choose a standard or expedited reconsideration

Standard reconsiderations normally must be requested in writing unless the plan accepts an oral request. An expedited request may be made orally or in writing. Ask for expedited handling when the standard timeframe could seriously jeopardize your life, health, or ability to regain maximum function.

If a physician supports the request and indicates that waiting creates that risk, the plan must process the reconsideration on an expedited basis. A fast review generally applies to care or a benefit you have not yet received, rather than a request for payment after the service was already provided.

4. Include the information needed to identify the case

Your name, address, and Medicare number.
The item, service, Part B drug, or payment being appealed.
The date of service or requested service, when applicable.
A copy of the organization determination notice.
A clear explanation of why you disagree.
Medical records, a physician statement, coverage criteria, or other evidence supporting the request.
Proof of representation if another person is acting as your appointed representative.
A request for expedited handling and the health reason, when applicable.

5. Send the appeal to the health plan

Use the telephone number, fax, secure portal, or mailing address in the denial notice or Evidence of Coverage. Do not send the level 1 request to CMS headquarters or to the Independent Review Entity. Keep a complete copy and proof showing when the plan received it.

6. Monitor the plan's response time

Standard pre-service appeal: no later than 30 calendar days after receipt.
Standard payment appeal: no later than 60 calendar days after receipt.
Standard Part B drug appeal: no later than 7 calendar days after receipt.
Expedited pre-service or Part B drug appeal: no later than 72 hours after receipt when expedited handling applies.

The plan may extend certain timeframes by up to 14 calendar days in limited circumstances, such as when more information is needed and the extension is in your interest. It must notify you and explain your rights. These timeframes are processing limits, not approval guarantees.

7. Review the decision and automatic level 2 review

If the plan approves the appeal, confirm when it will authorize, provide, or pay for the care. If the plan upholds the denial in whole or in part, it generally sends the case automatically to the Part C Independent Review Entity for level 2 review. Read the new notice carefully because later appeal levels have their own deadlines and, at some levels, a minimum amount in controversy.