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.
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