If you disagree with the initial decision (organization determination) from your plan, you, your representative, or your treating doctor can ask for a reconsideration (a second look or review), but you have to do so within 60 days of the date of the organization determination.
You or your doctor must make your request in writing, unless your plan allows you to file a request by phone, fax, or email.
Your written reconsideration request should include:
- Your name, address, and the Medicare number (health insurance claim number (HICN) shown on your Medicare card.
- The items or services for which you're asking for a reconsideration and the dates of service.
- Your signature. If you have appointed a representative, include the name and signature of your representative.
You should also include any other information that may help your case. Keep a copy of everything you send to your plan as part of your appeal.
How long your plan has to respond to your request depends on the type of request:
- Standard service request—30 days
- Payment request—60 days
- Fast request—72 hours
You'll get a fast request if your plan determines, or your doctor tells your plan, that your life or health may be at risk by waiting for a standard decision.
The time to complete standard service and fast requests may be extended by up to 14 days if, for example, your plan needs more information to make a decision about the case, and the extension is in your best interest.
If the plan decides against you (fully or partially), your appeal is automatically sent to level 2.
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