How to appeal a Medicare Advantage coverage denial

First, confirm your coverage

Medicare has separate appeal paths

Check what kind of decision the notice describes. A Medicare Advantage service denial, an Original Medicare claim decision, and a Part D prescription drug decision do not use one shared appeal process.

Use the plan’s process

Practical steps for a Part C reconsideration

1. 01

   Read the plan’s decision notice

   Keep the full notice. Find the date, the service or item involved, the decision or authorization number, and the exact reason the plan gives. Note whether it is refusing a service before you receive it, denying payment for care you already received, or ending an ongoing service.

   If the notice is unclear, contact the plan using the number on your member card or notice. Ask what decision it made, which plan rule or coverage term it applied, and how to get copies of the records or criteria it relied on.

   • Mark the appeal deadline and the submission method, address, fax number, or portal listed in the notice.
   • Check the relevant section of your Evidence of Coverage (EOC), including any coverage conditions, authorization rules, network terms, or limits cited by the plan.

   • Centers for Medicare & Medicaid Services (CMS): Reconsideration by a Medicare Advantage health plan (Part C)
   • Medicare.gov: Appeals in a Medicare health plan

2. 02

   Note the Part C appeal deadline

   For a Medicare Advantage plan reconsideration, CMS says to file within 65 calendar days of the date on the plan’s written organization-determination notice. If you may miss or have missed the deadline, contact the plan promptly and ask whether it can accept a late request; explain the reason and follow the plan’s instructions. Do not wait for a general guide to calculate or preserve your deadline.

   The 65-day period is for this first Part C reconsideration. It is not the Original Medicare or Part D deadline, and it may not fit a separate fast appeal for care that is ending.

   • Centers for Medicare & Medicaid Services (CMS): Reconsideration by a Medicare Advantage health plan (Part C)

3. 03

   Gather information that answers the denial reason

   Choose records that relate to the plan’s stated reason. A focused explanation can identify what you want the plan to review and point to the attached information. Your treating professional may be able to help explain clinical details or provide relevant records; ask what they consider appropriate to share.

   • The complete denial notice, insurance card details, service dates, and claim or authorization number.
   • The relevant EOC section, referral or prior-authorization request, itemized bill, or other plan correspondence.
   • Records or a statement from your treating professional that address the plan’s stated reason, when relevant.
   • The plan’s criteria or records it relied on, if you were able to obtain them, plus notes from calls or messages.
   • A copy of everything you send and proof of when and how the plan received it.

   • Centers for Medicare & Medicaid Services (CMS): Reconsideration by a Medicare Advantage health plan (Part C)
   • Medicare.gov: Appeals in a Medicare health plan

4. 04

   Send the reconsideration to your plan

   Use the form, address, fax, portal, or phone method in your notice and plan materials. A standard reconsideration is generally requested in writing unless the plan accepts an oral request. For an expedited reconsideration, Medicare guidance allows you or your representative to request it orally or in writing. Include your name and Medicare details, identify the decision, explain why you disagree, and attach relevant records.

   If someone else will act for you, ask the plan whether it needs a representative form or other written authorization. Keep the plan’s receipt confirmation and a complete copy of your submission.

   • Centers for Medicare & Medicaid Services (CMS): Reconsideration by a Medicare Advantage health plan (Part C)
   • Medicare.gov: Appeals in a Medicare health plan

5. 05

   Read the response and the next-step instructions

   The plan will send a written reconsideration decision. If it does not fully reverse the denial, the plan generally forwards the case automatically to an independent review entity for the next level; read the decision notice for what happens in your case and any later deadlines.

   If the decision is about the plan ending or stopping hospital, skilled nursing, home health, or hospice services you are already receiving, act immediately. The fast-appeal notice may set a much earlier deadline than the 65-day Part C reconsideration period. Medicare.gov notes that fast-appeal rules differ for Medicare Advantage, so follow your plan’s notice rather than an Original Medicare timeline and contact the plan or reviewer named there right away.

   • Centers for Medicare & Medicaid Services (CMS): Medicare Advantage plan appeals overview
   • Medicare.gov: Appeals in a Medicare health plan
   • Medicare.gov: Appeal a decision to stop care in a Medicare health plan