If you are in a Medicare Advantage plan, you can appeal the plan's decision to not pay for, not allow, or stop a service that you think should be covered or provided.
You may contact your plan or consult your plan materials for detailed information about requesting an appeal and your appeal rights.
How to Request an Appeal (i.e., "request for reconsideration")
- Your Medicare Advantage plan must inform you in writing on how to request an appeal.
- At Level 1, your appeal is called a request for reconsideration.
- You may request reconsideration by your Medicare Advantage plan within 60 days of being notified by your Medicare Advantage plan of its initial decision to not pay for, not allow, or stop a service ("organization determination").
When You Will Get a Response (i.e., "reconsideration decision")
In most cases, your plan will notify you of its reconsideration decision within:
- 30 days if the decision involves a request for a service.
- 60 days if the decision involves a request for payment.
Special Circumstances for Expedited Review
You or your physician may request an expedited reconsideration by your Medicare Advantage plan in situations where the standard reconsideration time frame might jeopardize your health, life, or ability to regain maximum function.
If you are receiving services in an inpatient hospital, skilled nursing facility, home health agency or comprehensive rehabilitation facility, you may request an immediate review by a Quality Improvement Organization, if you disagree with your Medicare Advantage plan's decision to discharge you or discontinue services.
Automatic Forward to Level 2 Appeals
Your Level 1 appeal ("reconsideration") will automatically be forwarded to Level 2 of the appeals process in the following instances:
Your plan does not meet the response deadline.
If your Medicare Advantage plan fails to meet the established deadlines, it is required to forward your appeal to an independent outside entity for a Level 2 review.
Your plan does not decide in your favor.
If during your Level 1 appeal ("reconsideration") your Medicare Advantage plan does not decide in your favor, it is required to forward your appeal to an independent outside entity for a Level 2 review.
Please note that the Office of Medicare Hearings and Appeals is responsible only for the Level 3 claims appeals and certain Medicare entitlement appeals and Part B premium appeals. OMHA is not responsible for levels 1, 2, 4, and 5 of the appeals process. OMHA provides additional information on other levels of appeals to help you understand the appeals process in a broad context.
