How to Appeal Medicare Advantage Denial

If you have a Medicare Advantage Plan and also were denied coverage for a health and wellness solution or thing that you have actually already gotten, you might pick to interest ask your plan to reconsider its decision. Comply with the actions listed below if you assume the denied health and wellness solution or thing need to be covered by your plan. Please see our chart for a short summary of the Medicare Advantage appeal procedure.

Keep in mind: You will follow different appeal procedures if your plan has actually refuted coverage for care you have not yet gotten or a prescription drug.

You ought to get a composed notification from your plan mentioning that it is not covering your wellness solution or item. This can either be an Explanation of Benefits (EOB) or a notice titled Notice of Denial of Payment. The notice ought to describe what you require to do to appeal and also the factor your treatment is not being covered.
If your EOB specifies that a solution was not paid for by your plan, call your plan to ask why. If it is a rejection, you must start your appeal.
Start your appeal by following the instructions on the notice you obtained from your plan. Make certain to submit your appeal within 60 days of the day on the notification.
You might be qualified for a great reason extension if you have a great reason for missing your appeal due date.
If your appeal is effective, your solution or product will be covered. Your plan ought to automatically forward your appeal to the next level, the Independent Review Entity (IRE).
If your plan misses the 60-day decision target date, your appeal will certainly be taken into consideration refuted, and also your plan needs to instantly ahead your attract the IRE.
If your IRE appeal is refuted and also your treatment is worth at the very least $160 in 2018, you can select to appeal to the Office of Medicare Hearings and Appeals (OMHA) degree. If you determine to appeal to the OMHA degree, you might want to get in touch with a lawyer or legal services company to aid you with this or later actions in your appeal-- however this is not required.
Your service or thing will be covered if your appeal to the OMHA degree is effective. If your appeal is rejected and also your wellness solution or thing deserves at least $160 in 2018, you can appeal to the Council within 60 days of the day on your OMHA degree denial letter. There is no decision timeframe for the Council to choose.
Your treatment will certainly be covered if your appeal to the Council is successful. If Source your appeal is denied and also your wellness service or thing deserves least $1,600 in 2018, you can appeal to the Federal District Court within 60 days of the day on your Council rejection letter. There is no timeframe for the Federal District Court to make a decision.


If you have a Medicare Advantage Plan and also were refuted insurance coverage for a health and wellness service or item that you have actually already received, you might select to appeal to ask your plan to reevaluate its decision. If your IRE appeal is denied and also your treatment is worth at least $160 in 2018, you can choose to appeal to the Office of Medicare Hearings and also Appeals (OMHA) level. If you decide to appeal to the OMHA level, you may want to contact a lawyer or lawful services organization to help you with this or later actions in your appeal-- however this is not required.
If your appeal is refuted and also your health and wellness service or thing is worth at the very least $160 in 2018, you can appeal to the Council within 60 days of the date on your OMHA degree rejection letter. If your appeal is denied and also your health and wellness service or item is worth the very least $1,600 in 2018, you can appeal to the Federal District Court within 60 days of the date on your Council denial letter.