Start with the written decision, not an assumption about why a claim was denied. A billing mistake, a coverage decision and a complaint about service may require different responses. This guide addresses medical coverage and payment questions.
Identify the correct process
For Original Medicare, review the Medicare Summary Notice. The first appeal is generally a redetermination, requested within 120 days of receiving the notice. Medicare Advantage has a plan appeal process and its own notice instructions. Use the deadline and submission method shown on the decision that applies to you.
Organize the request
- Identify the service, date and decision you disagree with.
- State clearly what correction or review you want.
- Ask the provider for relevant records or an explanation.
- Include the required form or information, following the notice.
- Keep copies and proof of submission.
If the issue may be billing
Compare the provider's bill with the coverage notice. Ask the billing office to check the submitted information. A request to correct a bill does not automatically extend an appeal deadline, so track both processes if necessary.
When timing affects health
Ask the plan or the contact on the notice whether a faster review is available for your situation. Different rules apply to some care-ending decisions; read those notices immediately. A representative may help, but the program or plan can require authorization.
Contact Medicare or SHIP if you need help understanding the process. No agent can guarantee the outcome of an appeal.
Continue with a related question
- Your Medicare Rights: Information, Privacy and Appeals
- How to Find and Verify a Medicare Provider
- Your Medicare Card: Replacement and Safe Use