Your Coverage & Care
Your Coverage & Care
 
Appealing Denied Claims

Appeal Process Overview - Medicare Plans Administered by Private Insurers

When you join a Medicare Advantage, Cost, Drug Coverage or Supplemental plan, you’re still in the Medicare program. The appeals process for these plans has five levels:

  • Level 1: Reconsideration from your plan (the private insurer that administers the plan dictates this level and it will likely be similar to the internal review process used for their commercial plans)
  • Level 2: Review by an Independent Review Entity (IRE)
  • Level 3: Hearing before an Administrative Law Judge (ALJ)
  • Level 4: Review by the Medicare Appeals Council (Appeals Council)
  • Level 5: Judicial review by a federal district court 

Getting Started

Before you begin the appeal process, here are some steps to get you organized

  1. Create a communication log or use our template
  2. Use it to keep track all communication - dates and types of correspondence (letters, phone calls, emails, faxes), names of people you speak with, summaries of your conversations, dates of packages sent and received
  3. Keep a paper and electronic file of original documents (e.g. letters, forms, medical records, insurance documents, medical journal articles)

Ask your doctor or other health care providers for information that may help your appeal, including:

  • A letter from your treating provider stating the medical reasons the service, procedure or medication should be approved. We have provided an example of an appeal letter from your physician.
  • Relevant medical records or treatment history from your physician.
  • Results of any relevant tests or procedures related to the requested service or procedure.
  • Peer-reviewed articles or studies documenting the medical effectiveness of the requested services or treatments being recommended.

At each level, you'll be given instructions in the decision letter on how to move to the next level of appeal. Keep a copy of everything you send to and receive from Medicare or the insurer who administers the plan as part of your appeal.

Centers for Medicare and Medicaid Services offers a brochure about the appeals process for Medicare Advantage and Medicare Drug Coverage. CMS’ website also has several resources available to help guide you step-by-step through the process.

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