Appeals if you have a Medicare health plan

Requesting an organization determination

You have the right to ask your plan to provide or pay for items or services you think should be covered, provided, or continued. The decision by the plan is called an "organization determination."
You, your representative, or your doctor can request an organization determination from your plan in advance to make sure that services are covered. If the plan denies coverage or payment after you receive services, that denial is the organization determination that you can appeal.
If a plan provider refers you for a covered service or to a provider outside the network, but doesn’t get an organization determination in advance, this is called “plan directed care.” In most cases, you won’t have to pay more than the plan’s usual cost sharing. Check with your plan for more information about this protection.
You don’t have to pay more than the plan’s usual cost-sharing for a service or supply if a network provider didn’t get an organization determination and either of these is true:
- The provider gave you or referred you for services or supplies that you reasonably thought would be covered.
- The provider referred you to an out-of-network provider for plan-covered services.
If the plan won't cover the items or services you asked for, you'll get a notice explaining why your plan fully or partially denied your request and instructions on how to appeal your plan's decision by requesting a reconsideration. If you appeal the plan’s decision, you may want to ask for a copy of your file containing medical and other information about your case. Your plan may charge you for this copy.

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.

What if I disagree with the organization determination?

If you disagree with your plan's initial decision, you can file an appeal. 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.