Note: If your plan will not approve care that you need and have not yet gotten, you are entitled to a faster appeal.

To find out what you can do if your plan refuses to pay for care that you need—and what to do if it is an emergency—click on the links in the GO TO Box.

Below are the steps you must take to file a “standard” appeal if your plan will not pay for care you already received. Make sure to keep any notices you receive from the plan and write down the names of any representatives you speak to and when you spoke to them.

1. Get a Denial Notice

The plan must send you a written denial notice before you can start the appeal.

The notice will tell you what information you need to send to the plan to start an appeal.

2. Request a Reconsideration

You have 60 days from the date on your denial notice to appeal to the plan (request a reconsideration).

In most cases, you will need to send a letter to the plan explaining why you needed the service. Ideally, you should also include a supporting statement from your doctor explaining why you needed the care (medical necessity).

3. Get the Plan’s Decision

Once you appeal, the Medicare private health plan must make a decision within 60 days. If you do not hear back, call the plan.

4. Get an Independent Review

If your plan still does not change its decision, it must forward your request to the next level of appeal—the Independent Review Entity (IRE) —automatically. The IRE is an independent group of doctors and other professionals that contracts with Medicare to ensure that you receive quality care.

The IRE must decide your case within 60 days.

5. Continue to Additional Levels of Appeals

If the IRE says the plan does not have to pay for the care you received (upholds the plan's denial), you must take active steps to continue the appeal.

You can appeal to an Administrative Law Judge (ALJ) (if the cost for the service in dispute is at least $130 in 2010). You must appeal to the ALJ within 60 days of the date on the IRE’s decision.

If you are turned down at the ALJ level, you can appeal to the Medicare Appeals Council (MAC) and then to Federal Court.

If you plan to appeal at the ALJ level or higher, you may want to find an advocate or lawyer to help you.
To find out when you can change your Medicare health plan, click on the link in the GO TO box.
For tips on what questions to ask if you are considering joining a Medicare private health plan, click on the link in the GO TO box.
To find out more about these additional levels of appeal, click on "Timeline for filing a Medicare private health plan appeal (standard)" in the GO TO box.