When initially filing an appeal An appeal is a formal request for review if you disagree with an official health care coverage or payment decision made by a Medicare Advantage Plan, a Medicare private drug plan (Part D), or Original Medicare. Federal regulations and law specify appeals deadlines, processes for handling appeals, what information must be included in a decision, and the levels of review in the appeals process. and for each subsequent level, you have a limited amount of time to file. That said, after the deadline has passed, if you can show good cause for not filing on time, your late appeal may be considered. You can request a good cause extension at any level of appeal, and it is available for Original Medicare Original Medicare, also known as Traditional Medicare, is the fee-for-service health insurance program offered through the federal government, which pays providers directly for the services you receive. Almost all doctors and hospitals in the U.S. accept Original Medicare. , Medicare Advantage Medicare Advantage, also known as Part C, Medicare Private Health Plan, or Medicare Managed Care Plan, allows you to get Medicare coverage from a private health plan that contracts with the federal government. All Medicare Advantage Plans must offer at least the same benefits as Original Medicare (Part A and Part B), but can do so with different rules, costs, and coverage restrictions. Plans typically offer Part D drug coverage as part of Medicare Advantage benefits. Medicare Advantage Plans include Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), Private Fee-for-Service (PFFS) plans, Special Needs Plans (SNPs), and Medicare Medical Savings Accounts (MSAs). , and Part D Part D, also known as the Medicare prescription drug benefit, is the part of Medicare that provides prescription drug coverage. Part D is offered through private companies either as a stand-alone plan, for those enrolled in Original Medicare, or as a set of benefits included with a Medicare Advantage Plan. appeals. Extension requests are considered on a case-by-case basis, so there is no complete list of acceptable reasons for filing a late appeal, but some examples include:
- The notice you are appealing was mailed to the wrong address.
- A Medicare representative gave you incorrect information about the claim you are appealing.
- Illness—either yours or a close family member’s—prevented you from handling business matters.
- The person you are helping appeal a claim is illiterate, does not speak English, or could not otherwise read or understand the coverage notice.
If you think you have a good reason for not appealing on time, send in your appeal as you normally would and include a clear explanation of why your appeal is late. If the reason has to do with illness or other medical conditions, a letter or supporting documentation from your health care provider A health care provider is an individual or facility (such as a doctor, hospital, or durable medical equipment (DME) supplier) that provides health care services and/or items. can be helpful.