Medicare Health Center

Tools & Resources

Font Size

How to File a Medicare Appeal

Ideally, Medicare will pay its share of your health costs without you having to do anything. In reality, it doesn't always work that way.

You may sometimes find that Medicare hasn't paid enough -- or at all -- for a drug, a doctor's visit, or a treatment that you needed. Perhaps Medicare stopped paying for a service or a drug it once covered. If that happens, and you feel that Medicare should pay, you can file a Medicare appeal. Filing a Medicare appeal might seem intimidating, but it's usually worth the effort.

Recommended Related to Medicare

Medicare Part B: Doctor Costs and Lab Tests

Medicare Part B pays for outpatient medical care, such as doctor's visits, home health services, some laboratory tests, some medications, and some medical equipment. (Hospital stays are covered under Medicare Part A.) If you qualify to get Medicare Part A, you're qualified for Medicare Part B as well. If you're 65 and receive Social Security checks, you're automatically enrolled. If you are 65 or older but don't get Social Security payments, you can still apply. Call Social Security at 800-772-1213,...

Read the Medicare Part B: Doctor Costs and Lab Tests article > >

More than 70% of Medicare appeals are successful. So if you put in the time, the odds are good that you'll get what you need.

Filing a Medicare Appeal

The process of filing a Medicare appeal depends on what type of plan you have.

Original Medicare Plan (Medicare Part A and Medicare Part B). Whenever Medicare approves (or denies) payment, you'll get a record of it on the "Medicare Summary Notice" you receive every three months in the mail. To file a Medicare appeal, here's what you do:

Look over the notice and circle the items in question.
Write down the reason you're appealing, either on the notice or on a separate piece of paper.
Sign it and write down your telephone number and Medicare number. Make a copy.
Send it -- or a copy -- to the Medicare contractor's address listed on the notice.
Include any other documentation that supports your appeal.

Make sure to file your Medicare appeal within 120 days of the date you received the Medicare Summary Notice.

You may also file a fast appeal if you believe Medicare should continue paying for a service. Your health care provider should provide you with a notice with instructions on filing. You need to call the Quality Improvement Organization listed on the notice to request a fast appeal. If you miss the deadline on the notice, call 1-800-MEDICARE (1-800-633-4227) to get the phone number of your state's Quality Improvement Organization.

Medicare Advantage. Filing an appeal is potentially a little trickier with Medicare Advantage plans. You're dealing not only with Medicare, but with the rules set by the private insurance company that runs your program.

So, you start by working through the individual insurer, which should have provided you instructions on how to make a Medicare appeal. If the insurer denies your claim, it is then reviewed by an independent group affiliated with Medicare.

If you think that your Medicare Advantage program's refusal is jeopardizing your health, ask for a "fast decision." The insurer is legally bound to get you a response within 72 hours.

Medicare Prescription Drug Plan. Again, the appeal processes differ, because Medicare Prescription Drug Plans are run by outside insurance companies with their own rules.

But in general, if your drug plan won't pay for a drug that you need, here are the steps you should take.

First, talk to your doctor about the situation to make certain that you can't take a different drug that is covered by your plan.
If that's not possible, ask your doctor to write an explanation about why you need this particular drug. (Be as specific as possible for why you need that particular drug.) Then either you or your doctor can submit the request to the Medicare drug plan. Usually, these requests are answered within three days, although you can request a faster decision. This is called a coverage decision.
If the drug plan denies your request, you or your designated representative can file a formal appeal by phone or mail. Find out how the appeal process works in your drug plan. Usually, you have to submit an appeal within 60 days of the original coverage determination. The plan must get back to you with a decision within a week, or 72 hours if you've requested an expedited decision. If you need help filing an appeal, get in touch with your state's State Health Insurance Assistance Program (SHIP.)
If the drug company denies your appeal, you can appeal again. But this time, your appeal goes to an independent organization that works for Medicare. Your insurer will give you instructions on how to file further Medicare appeals, should you need them.
If your Medicare Prescription drug plan doesn't respond to your request, you can file a grievance by calling 800-MEDICARE.

For more help understanding Medicare, see WebMD's list of Medicare Resources.

Slideshow: How to Protect Your Health Care in a Rough Economy