If you’ve received a denial for a Medicare Advantage claim, you have the right to challenge that decision through an appeals process. Navigating this process can feel overwhelming, but understanding your options can significantly improve your chances of success. This guide explains step-by-step how to appeal a denied Medicare Advantage claim in 2025, including how to write an appeal letter and strategies to strengthen your case.
Understanding Medicare Advantage Claim Denials
Medicare Advantage plans are offered by private insurance companies approved by Medicare. While these plans cover all Part A and Part B services, they can deny claims for several reasons, including:
- Services deemed not medically necessary
- Lack of prior authorization
- Incomplete documentation
- Treatment outside the plan’s network
Before you appeal, carefully review your denial notice, also called an Explanation of Benefits (EOB). This document explains:
- Why your claim was denied
- How you can file an appeal
- The deadline for filing
Steps to Appeal a Denied Medicare Advantage Claim in 2025
Appealing involves five levels, each offering an opportunity to overturn the denial:
1. Request a Reconsideration
This is the first level of appeal. Contact your plan within 60 days of receiving the denial. You or your doctor must submit:
- A written request for reconsideration
- Any supporting medical records or letters
- A copy of the denial notice
Tip: Ask your healthcare provider to include a statement explaining why the service is medically necessary.
2. Review by an Independent Organization
If the reconsideration is denied, the case automatically goes to an Independent Review Entity (IRE) for a second look. You’ll receive instructions if this happens.
3. Hearing Before an Administrative Law Judge
If the IRE upholds the denial and the disputed amount is at least $180 (2025 threshold), you can request a hearing before a judge. This level gives you a chance to present your case in detail.
4. Medicare Appeals Council Review
If you disagree with the judge’s decision, you can request a review by the Medicare Appeals Council.
5. Judicial Review in Federal District Court
The final option is to file a lawsuit in federal court if the amount in dispute meets the threshold ($1,840 in 2025).
How Do I Write an Appeal Letter for Medicare?
A clear and persuasive appeal letter is essential. Follow this structure:
Sample Appeal Letter Template
cssCopyEdit[Your Name]
[Your Medicare Number]
[Address]
[Phone Number]
[Date]
To Whom It May Concern,
I am writing to request a reconsideration of the denial for [service/treatment] provided on [date]. My Medicare Advantage plan denied this claim because [reason stated in the denial letter].
I believe this service is medically necessary because [briefly explain why]. Enclosed are supporting documents from my healthcare provider.
Please reconsider this decision based on the attached evidence.
Sincerely,
[Your Name]
Attachments to Include:
- Doctor’s statement
- Relevant medical records
- Denial notice
- Any prior authorization documents
What Is the Best Way to Win a Medicare Appeal?
While every case is unique, these strategies can improve your chances:
✅ Act Quickly: Respect all filing deadlines.
✅ Be Thorough: Include all necessary paperwork and detailed explanations.
✅ Get Professional Help: Consider assistance from:
- Your doctor’s billing office
- A Medicare counselor (SHIP program)
- An attorney experienced in Medicare appeals
✅ Follow Up: Confirm receipt of your appeal and keep copies of all correspondence.
Frequently Asked Questions
How long does a Medicare Advantage appeal take?
- Reconsiderations are usually resolved within 30 days, but expedited appeals can be faster if your health requires it.
Can someone else file the appeal for me?
- Yes, you can appoint a representative by completing an Appointment of Representative form (CMS-1696).
Do I have to pay for the service while waiting for the appeal?
- You may be responsible for payment during the appeal. If you win, you will be reimbursed.
Final Thoughts
Appealing a denied Medicare Advantage claim in 2025 doesn’t have to be intimidating. By understanding the process, preparing strong documentation, and seeking help when needed, you can improve your chances of overturning the denial.
Need Help?
For more information, visit Medicare.gov or call 1-800-MEDICARE (1-800-633-4227).
