Medicare health plan appeals - Level 1: Reconsideration from your plan

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 file a written standard or expedited (fast) request, unless your plan allows you to file a request by phone, fax, or email.

Note

Your doctor or other prescriber (for prescription drug appeals) can request this level of appeal for you, and you don’t need to appoint them as your representative.

Your written reconsideration request should include:

  • Your name, address, and the Medicare number shown on your Medicare card.
  • The items or services for which you're asking for a reconsideration and the dates of service.
  • If you've appointed a representative, include the name of your representative and proof of representation.

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:  

  • Expedited (fast) request—72 hours
  • Standard service request—30 days
  • Payment request—60 days

You'll get a fast request if your plan determines, or your doctor tells your plan, that waiting for a standard decision may seriously jeopardize your life, health, or ability to regain maximum function.

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 from a non-contract provider 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.