Original Medicare, Medicare Advantage, and Part D plans can deny coverage for a health service or medication. However, individuals have a legal right to appeal the decision if they think it is incorrect.
A person can submit an application form with a statement, as well as some supporting evidence, outlining why they disagree with Medicare’s decision.
Medicare will then review the information and either allow or refuse the appeal.
Glossary of Medicare terms
We may use a few terms in this article that can be helpful to understand when selecting the best insurance plan:
- Out-of-pocket costs: An out-of-pocket cost is the amount a person must pay for medical care when Medicare does not pay the total cost or offer coverage. These costs can include deductibles, coinsurance, copayments, and premiums.
- Deductible: This is an annual amount a person must spend out of pocket within a certain period before an insurer starts to fund their treatments.
- Coinsurance: This is the percentage of treatment costs that a person must self-fund. For Medicare Part B, this is 20%.
- Copayment: This is a fixed dollar amount a person with insurance pays when receiving certain treatments. For Medicare, this usually applies to prescription drugs.
People enrolled in Medicare have rights and protections surrounding their healthcare services. The Medicare appeals process is one of these rights.
It allows a person to appeal a Medicare decision about coverage denial or late payments, such as penalties.
The Medicare appeals process has five levels, each with a separate review process. If Medicare approves an appeal at the first level, the process stops. Alternatively, if Medicare denies the initial appeal, the process can go to the next level, and so on.
An individual must collect supporting documents from their doctor or other medical professional to prove their appeal case to Medicare. They will submit these documents, along with the appeal form, to Medicare.
People have the right to appeal if they disagree with Medicare’s decision not to approve the following:
- a request for a healthcare service, supply, item, or prescription drug that Medicare should cover
- a payment request for a healthcare service, supply, item, or prescription drug they have already received
- a request to change the amount someone pays for a healthcare service, supply, item, or prescription drug
Medicare may deny coverage for the following reasons:
- The item, service, or prescription drug is not medically necessary.
- An individual does not meet the eligibility requirements for coverage.
- Medicare does not cover the item, service, or prescription at any time.
Learn about understanding a Medicare denial letter.
Appealing monthly premium penalties
An individual can also appeal Medicare’s penalty decisions.
Late enrollment penalty
Medicare charges a late enrollment penalty if a person does not enroll in Original Medicare (parts A and B) or Part D when they first qualify, or if the person does not have other coverage from another source.
If a person had health insurance from an employer but Medicare charged a late enrollment penalty, the person can appeal that decision. Evidence needed to appeal will include proof of adequate coverage comparable with that of Medicare.
Learn more about Medicare late enrollment penalties.
Income-related monthly adjustment amount surcharge
Medicare assesses a person’s income as reported on their tax return from 2 years ago to calculate the Medicare Part B and Part D premiums. The Medicare income-related monthly adjustment amount (IRMAA) is a surcharge added to the standard premiums.
A person would be able to appeal an IRMAA surcharge if they disagree with Medicare’s assessment.
The appeal process starts when a Medicare beneficiary receives an official written notice that Medicare has denied coverage.
Standard notice types include:
- Medicare summary notice: A summary notice shows Medicare payments for covered services and items for the previous 3 months. It also indicates whether Medicare denies any item or service.
- Advance Beneficiary Notice of Noncoverage (ABN): Doctors and other healthcare professionals and suppliers issue ABN notices as an advanced warning that Medicare may not cover a service or drug.
- Skilled Nursing Facility Advance Beneficiary Notice (SNF ABN): If someone is staying in a skilled nursing facility and approaching the maximum number of covered days, the facility issues the SNF ABN.
- Fee-for-Service Advance Beneficiary Notice (FFS ABN): This notice tells someone that Medicare will charge them for a service they had or are due to receive.
- Notice of Denial of Medical Coverage (Integrated Denial Notice): Medicare Advantage plans and Medicaid issue these notices if they will not cover any part of a service.
- Hospital Issued Notice of Noncoverage (HINN): Hospitals use this form if Medicare coverage for inpatient stays is ending.
- Notice of Medicare Non-Coverage (NOMNC): This notice is similar to the HINN, but it refers to inpatient care in an SNF, rehabilitation facility, or hospice. A person will receive this at least 2 days before the coverage ends.
When Medicare sends out a notice, it includes information about the appeals process. However, the various Medicare parts have different methods for starting an appeal, as follows:
- Original Medicare (parts A and B): Usually, people must first complete a Redetermination Request form for an appeal against a decision involving Original Medicare.
- Medicare Part D: If a person wants to appeal a Part D decision, they will also usually need to begin by completing the Redetermination Request form.
- Medicare Advantage plans: Different rules apply to Medicare Advantage plans, and a person can contact their plan provider for information about appealing a decision.
Each appeals form requires basic personal information and some details of the claim. People must include details of the service or item they are appealing and why they think Medicare’s decision is incorrect.
They also need to provide supporting evidence, such as a doctor’s letter, test results, or diagnosis information.
Decision notification limits
Notifications of decisions have various time limits.
Medicare will generally provide a decision within 60 days of receiving the appeal.
It can take 24 to 72 hours for an expedited service request, and 14 days for a pre-service request.
The Medicare appeals process has five levels. If someone disagrees with a decision at any level, the appeal moves to the next level of review.
At each level, Medicare sends out a decision letter, which includes details of the next steps.
The levels are as follows:
- Level 1: This level is called redetermination. It is an initial review by a Medicare administrative contractor.
- Level 2: A qualified independent contractor reviews the appeal.
- Level 3: The Office of Medicare Hearings and Appeals (OMHA) reviews the appeal. The amount of the case must be at least $180.
- Level 4: The Medicare Appeals Council reviews the appeal.
- Level 5: This is a judicial review by a federal district court. The claim amount must be at least $1,840.
People should include as much supporting information as possible with the appeal. Information from doctors, other medical professionals, or suppliers can help an individual get a favorable decision.
Fast appeal
If waiting for a decision would affect a person’s health, they can ask for a fast appeal. An example of the need for a fast decision might be if someone is an inpatient in a hospital or SNF and they are concerned that the facility is discharging them too soon.
In that case, the person has a right to an immediate review by the Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO). The notice includes contact information.
While the BFCC-QIO is reviewing the case, the hospital cannot discharge the person, and they can stay in the hospital with no charge. The BFCC-QIO has 72 hours to decide the appeal.
A person in a nursing facility or other inpatient setting will get a notice at least 2 days before the coverage ends. The BFCC-QIO has until the end of the business on the day before an individual is due to be discharged to make a decision about the appeal.
Learn more about how to win a Medicare appeal.
The time limits for appeals depend on the Medicare part.
For Original Medicare (parts A and B), a person has 120 days from the day they received the notice to appeal.
With Medicare Advantage plans and Part D prescription drug coverage, a person has 60 days from the day they received the notice to file an appeal.
If a person decides to cancel a Medicare appeal, they should call Medicare at 800-MEDICARE (800-633-4227). They will need to provide the following information:
- their full name
- their Medicare ID number
- the date they submitted the appeal form
- details about the appeal
- the reason they are canceling the appeal
The Medicare appeals process does not have any associated costs.
People can find free help with the appeals process and any other Medicare matter at their local State Health Insurance Assistance Program.
Medicare resources
For more resources to help guide you through the complex world of medical insurance, visit our Medicare hub.
If Medicare denies coverage of an item or service, an individual has the right to appeal the decision. People must provide proof with a claim and submit this to Medicare with an application form.
The appeals process has five levels, and each has different reviewers. The appeal will move to the next level if the review board refuses the appeal.
Typically, Medicare decides within 60 days, but people can get a fast appeal if it concerns an inpatient stay and if waiting for a decision could affect their health.