If you are being prescribed a service—for example a test or a surgery—or you need to see a specialist, and your plan refuses to agree to pay for this care (grant you prior authorization), you can file an appeal.

Note: If you are being denied coverage for a prescription drug, you must use the Medicare private drug plan “exceptions” process to ask your health plan to cover a drug you need.

To find out what to do if your Medicare private health plan refuses to cover a drug you need, click on “What can I do if the drug I need is not covered by my Medicare drug plan or is too expensive?”

There are several steps to the appeals process and deadlines you must meet. Below are the steps you must take to file a “standard” appeal for care.

To find out how to appeal if you plan won't let you get care you need immediately, or denies payment for care you already received, click on the link in the GO TO box.

1. Get a denial from the Plan

You will need the plan to make an official decision before you can start the appeal. You will generally need this decision in writing. If your doctor or plan denied care, you should call and ask the plan to send you a denial notice. If you called the plan to request that they cover a service (for example, you requested prior authorization—special permission—to see a specialist), and the plan representative said no, remind the person to send you the decision in writing.

The plan should mail you a denial notice within approximately two weeks. The notice will tell you what information you need to send to the plan to start an appeal and where to send it.

Note: If you don't get a denial notice within two weeks, you can file an appeal without it unless you've received word from the plan that they need extra time to review your case (they can extend by up to two weeks). Send a letter to your plan explaining that it has been 14 days and you have not received a denial notice. Include a doctor’s supporting statement explaining why you need the care. In doing this, you will be starting the next part of the process, “requesting a reconsideration.”

2. Request a Reconsideration

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

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

3. Get the Plan's Decision

Once you appeal, the plan must make a decision within 30 days. (The plan has 14 extra days to gather information if it is in your best interest, but must notify you if it needs this extra time). If you do not hear back, call the plan.

4. Get an Independent Review

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

The IRE must decide your case within 30 days.

5. If necessary, 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 reconsideration notice.

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.

If it is during an enrollment period, you may want to consider disenrolling to take Original Medicare, or changing to another private health plan if you can find one that covers what you need.

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.

Note: Plans must meet deadlines for processing requests within the timeframes stated below but are technically required by law to do so as quickly as your health requires. 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.