Medicare Advantage post-service standard appeals

If you have a Medicare Advantage Plan and were denied coverage for a health service or item that you have already received, you may choose to appeal to ask your plan to reconsider its decision. Follow the steps below if you think the denied health service or item should be covered by your plan. Please see our chart for a brief outline of the Medicare Advantage appeal process.

Note: You will follow different appeal processes if your plan has denied coverage for care you have not yet received or a prescription drug.

1. You should receive a written notice from your plan stating that it is not covering your health service or item. This can either be an Explanation of Benefits (EOB) or a notice titled Notice of Denial of Payment. The notice should explain what you need to do to appeal and the reason your care is not being covered.
   1. Remember, an EOB is not a bill. If your EOB states that a service was not paid for by your plan, call your plan to ask why. It may be a billing or coding error. If it is a denial, you should begin your appeal.
2. Start your appeal by following the instructions on the notice you received from your plan. Make sure to file your appeal within 60 days of the date on the notice. You will most likely need to send a letter to the plan explaining why you needed the service you received. You may also want to ask your doctor to write a letter of support, explaining why you need care and addressing the plan’s concerns. Your plan should make a decision within 60 days.
   1. If you have a good reason for missing your appeal deadline, you may be eligible for a good cause extension.
3. If your appeal is successful, your service or item will be covered. If your appeal is denied, you should receive a written denial notice. Your plan should automatically forward your appeal to the next level, the Independent Review Entity (IRE). The IRE should make a decision within 60 days of the date on your plan denial notice.
   1. If your plan misses the 60-day decision deadline, your appeal will be considered denied, and your plan should automatically forward your appeal to the IRE.
4. If your appeal to the IRE is successful, your service or item will be covered. If your IRE appeal is denied and your care is worth at least $160 in 2018, you can choose to appeal to the Office of Medicare Hearings and Appeals (OMHA) level. You must file your OMHA level appeal within 60 days of the date on your IRE denial letter. If you decide to appeal to the OMHA level, you may want to contact a lawyer or legal services organization to help you with this or later steps in your appeal—but this is not required.
5. If your appeal to the OMHA level is successful, your service or item will be covered. If your appeal is denied and your health service or item is worth at least $160 in 2018, you can appeal to the Council within 60 days of the date on your OMHA level denial letter. There is no decision timeframe for the Council to make a decision.
6. If your appeal to the Council is successful, your care will be covered. If your appeal is denied and your health service or item is worth least $1,600 in 2018, you can appeal to the Federal District Court within 60 days of the date on your Council denial letter. There is no timeframe for the Federal District Court to make a decision.