If your Part C Medicare Advantage claim is denied — for people in a Medicare Advantage plan

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Overview

If you are unhappy with a decision made by your Medicare Advantage (MA) plan about your health care, you have 4 options:

• You can argue your case through the appeals process.
• You can request an expedited appeal, if appropriate.
• You can request a fast-track appeal, if appropriate.
• You can file a complaint through the internal grievance procedure.

You can also appoint someone else – a family member, friend, caregiver or doctor – to be your representative in an appeal or complaint.

Your MA plan is required to include this information on the appeals and grievance processes in its membership materials, and give this information to each enrollee.

Note that if you are unhappy with a decision made by your MA plan about prescription drugs, there is a separate appeals process. See our section on Medicare Prescription Drug Coverage Appeals.

Common appeals situations

Under the following situations, you can appeal your MA plan’s decisions:

• If you have been denied payment for using medical services received outside the MA plan in an emergency or urgent care situation, or for using other medical services when you couldn't get the care you needed within the MA plan.
• If your MA plan refused to give you or failed to give you treatment in a timely manner that you feel would otherwise be covered by Medicare. (In some cases, an expedited appeal may be in order.)
• If your MA plan discontinues services you believe are still medically necessary.

To learn more, see Your Options to Appeal

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Page updated October 8, 2008