Filing an appeal

If you disagree with a coverage or payment decision by Original Medicare , your Medicare Advantage or other Medicare health plan , or your Medicare drug plan you can file an appeal.

Before you start an appeal, ask your provider or supplier for any information that may help your case. If you’re in a Medicare Advantage plan, other health plan, or a drug plan, check your plan materials, or contact your plan, for details about your appeal rights. The plan must tell you, in writing, how to appeal. Generally, you can find your plan's contact information on your plan membership card.

You can file an appeal if Medicare or your plan refuses to:

• Cover a health care service, supply, item, or drug you think Medicare should cover.
• Pay for a health care service, supply, item, or drug you already got.
• Change the amount you must pay for a health care service, supply, item, or drug.

You can also file an appeal if:

• Medicare or your plan stops providing or paying for all or part of a health care service, supply, item, or drug you think you still need.
• Your plan’s drug management program labels you as “at-risk” because you meet the Overutilization Monitoring System criteria. This means your plan limits your access to coverage for drugs like opioids and benzodiazepines.

What if I want to challenge a Local Coverage Determination?

How do appeals work?

The appeals process varies based on the kind of coverage you have. Generally, there are 5 levels of appeals. If you disagree with the decision made at any level of the process, you can usually go to the next level. At each level you'll get a decision letter with instructions on how to move to the next level of appeal.

Get specific information on how to file an appeal based on the kind of coverage you have:

Can someone help me file an appeal?

State Health Insurance Assistance Program (SHIP): Visit shiphelp.org to get the phone number for your local SHIP and get free, personalized health insurance counseling. SHIPs are state programs that get money from the federal government to give free local health insurance counseling to people with Medicare.

Representative: If you have a trusted family member or friend helping you with a complaint, you can appoint them as a representative. How do I appoint a representative?

Your right to a fast appeal

You also have the right to a fast appeal if you think your Medicare-covered services are ending too soon. This includes services you get from a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility or hospice.

Your provider will give you a written notice before your services end that tells you how to ask for a fast appeal. If they don’t give you this notice, ask for it. Learn more about how fast appeals work.