How do I file an appeal?

An appeal is the action you can take if you disagree with a coverage or payment decision by Medicare or your Medicare plan. For example, you can appeal if Medicare or your plan denies:

  • A request for a health care service, supply, item, or drug you think Medicare should cover.
  • A request for payment of a health care service, supply, item, or drug you already got.
  • A request to change the amount you must pay for a health care service, supply, item, or drug.

You can also appeal:

  • If Medicare or your plan stops providing or paying for all or part of a health care service, supply, item, or drug you think you still need.
  • An at-risk determination made under a drug management program that limits access to coverage for frequently abused drugs, like opioids and benzodiazepines.
Appeals in Original Medicare
  • If you have Original Medicare, start by looking at your "Medicare Summary Notice" (MSN). You must file your appeal by the date in the MSN. If you missed the deadline for appealing, you may still file an appeal and get a decision if you can show good cause for missing the deadline.
  • Fill out a "Redetermination Request Form [PDF, 100 KB]" and send it to the company that handles claims for Medicare. Their address is listed in the "Appeals Information" section of the MSN.
  • Or, send a written request to company that handles claims for Medicare to the address on the MSN.
  • Include this information in your written request:
    • Your name, address, and the Medicare Number on your Medicare card [JPG].
    • Circle the items and/or services you disagree with on the MSN. Or, list the specific items and/or services for which you're requesting a redetermination, and the dates of service.
    • An explanation of why you think the items and/or services should be covered.
    • The name of your representative, if you’ve appointed a representative.
    • Any other information that may help your case.

You’ll generally get a decision from the Medicare Administrative Contractor within 60 days after they get your request. If Medicare will cover the item(s) or service(s), it will be listed on your next MSN.

Learn more about appeals in Original Medicare.

Coming soon: Appeal when a hospital changes your status from an inpatient to an outpatient with observation services


As a result of a court order, you have appeal rights when a hospital changes your status from inpatient to outpatient if you meet certain criteria. Your hospital status affects how much you pay for hospital services. Your hospital status may also affect whether Medicare will cover care you get in a skilled nursing facility (SNF) after your hospital stay.

You’ll have the right to file an appeal when a hospital changes your status from an inpatient to an outpatient, if you meet all of these requirements:

  • You were admitted to the hospital as an inpatient on or after January 1, 2009.
  • The hospital changed your status from “inpatient” to “outpatient” and after the status change you were an outpatient getting observation services.
  • You got a Medicare Outpatient Observation Notice (MOON) or a Medicare Summary Notice (MSN) telling you that observation services aren’t covered under Part A (Hospital Insurance) .

And you ALSO meet 1 of these 2 requirements:

  1. You weren’t enrolled in Part B (Medical Insurance) coverage when you were hospitalized, OR
  2. You had Part B coverage when you were hospitalized, and you:
    • Stayed at the hospital for 3 or more days in a row, but were not an inpatient for 3 days, AND
    • Were admitted to a skilled nursing facility during the 30 days after your hospital stay (or, it’s been less than 30 days since your hospital stay).
Even if you meet these requirements, you can’t file an appeal through this new process if you filed an administrative appeal about your hospital or skilled nursing facility services, and got a final decision before September 4, 2011.

If you meet all of these requirements, you’ll have the right to file an appeal about the change in your hospital status from inpatient to outpatient. 

The appeal process for this new type of appeal is still under development and not currently available. You’ll be able to file an appeal once the process is set up.  More information on how to file this type of appeal will be posted on Medicare.gov when it’s available.

Appeals in a Medicare health plan
  • If you have a Medicare health plan, start the appeal process through your plan. Follow the directions in the plan's initial denial notice and plan materials.
  • You, your representative, or your doctor must ask for an appeal from your plan within 60 days from the date of the coverage determination. If you miss the deadline, you must provide a reason for filing late. 
  • Include this information in your written request:
    • Your name, address, and the Medicare Number 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.
    • The name of your representative and proof of representation, if you’ve appointed a representative.
    • Any other information that may help your case.
  • If you think your health could be seriously harmed by waiting the standard 14 days for a decision, ask your plan for a fast or "expedited" decision. The plan must give you its decision within 72 hours if it 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.

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 calendar days
  • Payment request—60 calendar days

Learn more about appeals in a Medicare health plan.

 
Appeals in a Medicare Prescription Drug Plan
  • If you have a separate Medicare drug plan, start the appeal process through your plan.
  • If you're asking to get paid back for drugs you already bought, you or your prescriber must make the standard request in writing. Write your plan a letter, or send them a completed "Model Coverage Determination Request" form. Find the form and instructions at the bottom of the page under "Downloads."
  • If you're asking for a prescription you haven't gotten yet, you or your prescriber can ask your plan for a coverage determination or an exception. To ask for a coverage determination or exception, you can do one of these:
    • Send a completed "Model Coverage Determination Request" form.
    • Write your plan a letter.
    • Call your plan.
    • If you're asking for an exception, your prescriber must provide a statement explaining the medical reason why the exception should be approved.
  • If you didn't get the prescription yet, you or your prescriber can ask for an expedited (fast) request. Your request will be expedited if your plan determines, or your prescriber tells your plan, that waiting for a standard decision may seriously jeopardize your life, health, or ability to regain maximum function.

How long your plan has to respond to your request depends on the type of request:  

  • Expedited (fast) request—24 hours 
  • Standard service request—72 hours 
  • Payment request—14 calendar days

Learn more about appeals in a Medicare Prescription Drug Plan.

Appeals in PACE

If you have coverage through 

Program Of All-Inclusive Care For The Elderly (Pace)

, your appeal rights are different. The PACE organization will provide you with written information about your appeal rights.

Appeals in a Special Needs Plan 

If you have coverage through a

Medicare Special Needs Plan (Snp)

, your plan must tell you in writing how to appeal. After you file an appeal, the plan will review its original decision. If your plan doesn't decide in your favor, the appeal is reviewed by an independent organization. The independent organization works for Medicare, not for the plan.

​​​​​If you decide to appeal

If you decide to appeal, ask your doctor, health care provider, or supplier for any information that may help your case. See your plan materials, or contact your plan for details about your appeal rights.

Generally, you can find your plan's contact information on your plan membership card. Or, you can search for your plan's contact information.

The appeals process has 5 levels. If you disagree with the decision made at any level of the process, you can generally go to the next level. At each level, you'll get instructions in the decision letter on how to move to the next level of appeal.

Note:

  • Write your Medicare Number on all documents you submit with your appeal request.
  • Keep a copy of everything you send to Medicare as part of your appeal.