To appeal a Medicare Advantage denial, you, your representative, or your doctor must file a request for reconsideration with your plan within 65 days from the date on the plan's denial notice. The plan generally has 30 days to decide on a service you haven't gotten yet, 60 days for a payment appeal, and 72 hours for a fast appeal when your health could be at risk. If the plan still says no, your case goes automatically to an independent reviewer.
What counts as a denial in a Medicare Advantage plan?
Medicare.gov calls a plan's coverage decision an "organization determination." A denial can mean the plan refused to:
- Approve a service or item before you get it (often called prior authorization).
- Pay for care you already got.
- Keep paying for ongoing care.
You'll usually get a written denial notice. Your Explanation of Benefits (EOB) may also show a claim as denied with a reason code. If you only see it on the EOB, call the plan and ask for the formal denial notice, since your appeal deadline is based on its date.
What are the deadlines for a Medicare Advantage appeal?
Here are the timelines Medicare.gov lists for Medicare Advantage appeals:
| Step | Deadline |
|---|---|
| You file a Level 1 appeal (reconsideration) | Within 65 days from the date on the denial notice |
| Plan decides: service you haven't gotten yet | 30 days |
| Plan decides: payment for care you already got | 60 days |
| Plan decides: Part B drug | 7 days |
| Plan decides: fast (expedited) appeal | 72 hours |
Medicare.gov says these time frames can be extended by up to 14 days in some cases, and the plan must tell you in writing if it takes an extension.
If you miss the 65-day deadline, you must give a reason for filing late.
When should I ask for a fast appeal?
Ask for a fast (expedited) appeal if waiting the standard 30 days could seriously harm your health. Medicare.gov says the plan must decide within 72 hours if it determines, or your doctor tells the plan, that waiting could seriously jeopardize your life, health, or ability to regain maximum function.
A request backed by your doctor carries the most weight. Ask your doctor's office to call or write to the plan and say the case is urgent.
Fast appeals apply to care you haven't gotten yet. A payment appeal for a past bill uses the standard timeline.
What should I say in a Medicare Advantage appeal?
Follow the instructions on your denial notice. Medicare.gov says your appeal should include:
- Your name, address, and Medicare Number (and your plan member ID).
- The items or services you're appealing and the dates of service.
- The reasons you're appealing.
- Your representative's name and proof of representation, if you have one.
- Any other information that makes your case stronger, like a doctor's note.
Keep the letter short. Address the plan's specific reason for the denial. Here's sample wording:
I am requesting a reconsideration of [plan name]'s decision dated [date on denial notice] denying [service or item] for [date of service, or "requested by Dr. (name)"]. My member ID is [number].
The denial says [quote the reason]. I disagree because [your reason: for example, "my doctor ordered this test after two other treatments did not work," or "this provider was listed as in-network when I booked the appointment"].
I have enclosed [a letter from Dr. (name) / my medical records / a copy of the provider directory listing]. Please reverse this decision.
If the denial was for a missing prior authorization, ask your doctor's office whether they requested it. Medicare.gov describes "plan directed care": if a plan provider refers you for a covered service or to an out-of-network provider without getting an approval first, in most cases you won't have to pay more than the plan's usual cost sharing.