What Are Medicare Appeals?An appeal is a formal request for review of a decision made by your Original Medicare, Medicare Advantage, or Part D plan. If you were denied coverage for a health service or item, you may appeal the decision.

Before you start any appeal, make sure you fully read all the letters and notices sent by Medicare and/or your plan. Call 1-800-MEDICARE or your private health or drug plan to learn why your coverage is being denied, if the information was not provided. Your appeal letter should address the reason(s) for denial stated by Medicare or your plan. You can strengthen your appeal by including a letter of support from your doctor.

There is more than one level of appeal, and you have the right to continue appealing if you are not successful at the first level. Be aware that at each level there is a separate timeframe for when you must file the appeal and when you will receive a decision. Make sure to file each appeal in a timely manner. If there is a reason you cannot submit your appeal within the timeframe, see whether you are eligible for a good cause extension (see What are Some Tips for Making a Strong Appeal?). Otherwise, your appeal may not be considered. Keep in mind that an appeal is different from a grievance (see When and How Should I File a Grievance?). A grievance is a formal complaint that you file with your plan.

A standard appeal is an appeal of a denial for a health care service, item, or prescription drug that is covered by Medicare Part A or B. Keep in mind that you will follow a different appeals process than the ones listed below if you are appealing the denial of a Part D-covered prescription drug or if you disagree with a hospital’s or skilled nursing facility’s decision to discharge you or with a home health agency’s or hospice’s decision to end your care.

Read Next: How Can I File a Standard Appeal with Original Medicare?
Learn About: How Can I File a Pre-Service Standard Appeal with My Medicare Advantage Plan?
Return to: Medicare In-Depth

Clicking third-party links will open a new tab and will take you away from YourMedicare.com. YourMedicare.com, LLC does not control the linked sites’ content or link.

This content was created and copyrighted by the Medicare Rights Center ©2020. Medicare Rights Center is a national, nonprofit consumer service organization that works to ensure access to affordable health care for older adults and people with disabilities. These materials are presented here with support from YourMedicare.com and may not be distributed, modified or edited without Medicare Rights’ consent.

YourMedicare.com takes pride in providing you as much information as possible concerning your Medicare options, but only a health insurance broker licensed to sell Medicare can help you compare your plan options from various insurance companies. When you’re ready, we recommend you discuss your needs with a YourMedicare.com Licensed Sales Agent.