If you disagree with the initial decision (also known as the organization determination) from your plan, you or your representative can ask for a reconsideration (a second look or review). But, you have to ask for a reconsideration within 60 days of the date of the organization determination. If your appeal is for a service you haven’t gotten yet, your doctor can request a reconsideration on your behalf and must notify you about it.
You, your representative, 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.
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.
Include this information in your written reconsideration request:
- Your name, address, and the Medicare number shown on your Medicare card [JPG].
- The items or services for which you're requesting a reconsideration, the dates of service, and the reason(s) why you're appealing.
- If you've appointed a representative, include the name of your representative and proof of representation.
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 service decision may seriously jeopardize your:
- Ability to regain maximum function
The time to complete standard and fast service requests may be extended by up to 14 days in some cases. 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. Your plan will notify you in writing if it decided to take an extension. Your plan will notify you of the reasons for the delay and inform you of your right to file an expedited (fast) grievance if you disagree with the plan’s decision to take an extension.
If the plan decides against you (fully or partially), your appeal is automatically sent to level 2.