Disagreeing With Your Plan

Understanding the appeals process

Updated on: May 3, 2019

Originally posted on: July 2, 2015
by
The Roadmap for Medicare staff specialize in all topics related to Medicare Part D, choosing a Medicare plan, and making smart health decisions in retirement.

When you disagree with a coverage or payment decision made by your Medicare plan, you have the right to appeal so that the determination is reconsidered. Here’s important information to know before you appeal.

When Should You Appeal?

Whether you have Original Medicare only or with a Medicare prescription drug plan, or a Medicare Advantage Plan with or without prescription drug coverage, your rights will be the same. The way to make an appeal, however, may be different.

You may appeal a decision if Medicare, your Medicare health plan or Medicare Part D plan:

  • Denies a request for a healthcare service, supply, item or prescription drug that you think you should be able to get or have already received;
  • Denies a request to change the amount you must pay for a healthcare service, supply, item or prescription drug; or
  • Stops providing or paying for all or part of a healthcare service, supply, item or prescription drug you think you still need.

Deciding to Make an Appeal

How to file an appeal depends on the type of Medicare coverage you have, so be sure to review the rules that apply to you. Before you get started, your plan is required to tell you in writing how to file an appeal. To make this request, look for the appropriate contact information on your plan’s membership card. If it’s not on the card, check the plan’s website or call Customer Service.

It’s a good idea to have as much information as possible from your doctor or other healthcare provider or supplier to support your appeal.

If you’re uncomfortable making the appeal yourself, you can contact your State Health Insurance Assistance Program (SHIP) for help. Or you can appoint a representative, such as a family member or friend, advocate or attorney, or request that your doctor file an appeal on your behalf.

Something to Keep in Mind:
Appeals must be made within 60 days of the initial decision by your plan to deny coverage. If you or your doctor feels that your health would be put at risk by waiting on the plan’s decision, you may request a fast appeal and your plan must respond within 72 hours. 

The Appeals Process for Medicare Prescription Drug Coverage

If you’re concerned about the denial of coverage of a specific medication, consider asking your pharmacist if there are other medications that are as effective as the one you were prescribed and then discuss that option with your doctor before you appeal.

If you decide to appeal, you can expect the process to have five levels. If you disagree with the decision at any level, you generally have the option to move to the next level. At each level you receive a written decision, which will contain the instructions for how to move to the next level of appeal.

5 levels of the appeals process:

1. Redetermination by your plan
2. Review by an Independent Review Entity (IRE)
3. Hearing before an Administrative Law Judge (ALJ)
4. Review by the Medicare Appeals Council (Appeals Council)
5. Judicial review by a federal district court

Remember, if you need help filing an appeal, you can always contact your State Health Insurance Assistance Program.