Your Medicare Advantage plan said no: what to do next

Start with the denial letter

When you, your doctor or a provider asks a Medicare Advantage plan to cover a service, approve a prior authorization or pay a bill, the plan's answer is called an organization determination. If the answer is no, in whole or in part, or the plan cuts back or stops a course of treatment it had approved, the plan must send you a written notice. That notice has to:

• state the specific reasons for the denial;
• tell you that you have the right to a reconsideration (the first level of appeal);
• for a service or a Part B drug, describe both the standard and the fast appeal, and the conditions for a fast one.

Keep the letter. The date printed on it starts your appeal clock, and the reason it gives is what your appeal has to answer. "Not medically necessary" calls for medical records and a doctor's letter; "not a covered benefit" or "out of network" calls for the plan's own Evidence of Coverage.

The plan also has deadlines for its first answer. If it misses them, that counts as a denial, and you can appeal it.

For services and items, the plan can take up to 14 extra calendar days in some cases, for example when it needs records from a provider outside its network. It has to tell you in writing why, and you can file a fast complaint (an expedited grievance) if you disagree with the delay. Requests for payment follow Medicare's prompt-payment rules.

Level 1: ask the plan for a reconsideration

The first appeal goes back to the plan. The deadline is 65 days from the date on the denial notice. If you file late, do it in writing and say why; the plan can accept a late request for good cause.

Medicare.gov lists what to include:

• your name, address and Medicare Number;
• the items or services you're appealing, the dates of service, and why you disagree;
• if someone is appealing for you, their name and proof that they represent you;
• anything that supports your case, such as a doctor's letter and medical records.

The reconsideration has to be done by people who weren't involved in the first decision. If the denial was about medical necessity, it has to be decided by a physician with expertise in the right field of medicine.

For services, the plan can again extend by up to 14 days in some cases and must tell you in writing. The Part B drug deadlines can't be extended. If the plan misses its deadline, the case moves to the next level as if it had said no.

Fast appeals when your health can't wait

You can ask for a fast (expedited) decision, at the first request or at the appeal, if waiting the standard time could seriously jeopardize your life, your health or your ability to regain maximum function. The request can be made by phone or in writing.

• If you ask, the plan decides whether your situation meets that test.
• If your doctor asks, or supports your request and says the standard wait could seriously jeopardize your health, the plan must give you the fast timeframe. Any doctor can do this, whether or not they're in the plan's network.
• Fast appeals are for care you haven't received yet. A request to be paid back for care you already had always goes through the standard process.
• If the plan refuses to speed it up, it must move your request to the standard timeframe, tell you promptly, and send a letter within 3 calendar days explaining that you can file a fast complaint and can ask again with a doctor's support.

A plan isn't allowed to penalize a doctor for asking for, or supporting, a fast decision on your behalf.

Ask your doctor to back the appeal

When a denial says the records don't show why you need a service, the person who can answer that is the doctor who ordered it. Ask the office for:

1. A short letter explaining why you need the service, what was tried before, and what happens if you wait or go without.
2. The office notes and test results that support it, sent to the plan with your appeal.
3. For a service you haven't had yet, the doctor can file the reconsideration directly, as long as you're told.
4. If your health is at risk, a clear statement that the standard timeframe could seriously jeopardize your health. That is what makes a fast appeal mandatory.

Level 2: the outside review is automatic

If the plan keeps its denial, even partly, it must send your case file to an Independent Review Entity, an outside organization that contracts with Medicare and doesn't work for the plan. You don't need to file anything for this step. For a fast appeal, the plan has to forward the file within 24 hours of its decision.

Medicare.gov says this reviewer works to the same deadlines as the plan: 30 days for a service, 60 days for payment, 7 days for a Part B drug and 72 hours for a fast appeal, with extensions of up to 14 days possible.

Levels 3 to 5, briefly

• Level 3, a hearing with an Administrative Law Judge at the Office of Medicare Hearings and Appeals. You have 60 days from the level 2 decision to ask, and the amount in dispute has to meet a minimum Medicare sets each year. The hearing is usually by phone or video, or you can ask for a decision on the record without one.
• Level 4, the Medicare Appeals Council. 60 days after the judge's decision.
• Level 5, federal district court. 60 days after the Council's decision, with a higher yearly minimum amount.

If your case reaches level 3, this is the point to talk to an attorney or a legal-services program that handles Medicare cases. I'm not a lawyer, and this page describes how the process works rather than giving legal advice on a particular case.

When the plan ends a hospital or rehab stay

A plan deciding you're ready to leave the hospital, or that your skilled nursing, home health or outpatient rehabilitation care should stop, has its own faster appeal, decided by a reviewer outside the plan. For a hospital discharge, that reviewer is the Medicare quality improvement organization (QIO). For New York, the QIO is Commence Health, the contractor formerly called Livanta, at 1-866-815-5440. For the other services, the notice you receive names the reviewer and how to reach it.

Leaving the hospital

• The hospital must give you a written notice of your rights, called An Important Message from Medicare, no later than 2 days after you're admitted, and a copy again before discharge if more than 2 days have passed.
• The plan needs the agreement of the doctor responsible for your inpatient care before discharging you.
• To appeal, call the QIO no later than the day you're due to leave. The plan has to explain its decision, and the burden is on the plan to show discharge is right. The QIO decides within one calendar day of getting the information it needs.
• If you ask in time, and the plan approved the admission or it was emergency or urgently needed care, the plan keeps paying for the stay until noon of the day after the QIO tells you its decision.
• If you miss that deadline, you can still ask the plan for a fast reconsideration, but that protection doesn't apply.

Skilled nursing, home health or outpatient rehabilitation

• The provider must give you a written notice of the plan's decision to end covered services at least two days before they end.
• To appeal, contact the reviewer named on that notice by noon of the day after you receive it, by phone or in writing.
• Coverage continues until the date and time on the notice unless the reviewer reverses the plan's decision. The plan has to show that ending coverage is right.
• If you're late, the reviewer still takes the request, but the deadline protections don't apply.

For what Medicare pays in a skilled nursing facility and why hospital status matters, see does Medicare cover nursing home care? and observation status versus inpatient.

Drug denials work a little differently

If your plan includes drug coverage and won't cover a prescription, that decision is a Part D coverage determination, with its own steps:

• The plan must answer a coverage request within 72 hours, or 24 hours if it's expedited.
• An exception asks the plan to cover a drug that isn't on its list, or to charge a lower tier. It needs a supporting statement from your prescriber, and the clock starts when the plan receives that statement.
• If the answer is no, ask the plan for a redetermination within 65 days of the notice. The plan decides within 7 days, 72 hours if expedited, or 14 days if you're asking to be paid back.
• If the plan says no again, the decision explains how to ask the Part D Independent Review Entity to review it.

More on how drug plans and formularies work: Part D plans in the Capital Region.

Getting help in New York

• Your plan's member services can tell you where to send the appeal and confirm it was received. Write down the date, the name and any reference number.
• HIICAP, New York's free Medicare counseling program, helps with appeals and sells nothing. The Capital Region offices and phone numbers are on the HIICAP page.
• The denial notice itself names the process and the addresses that apply to your case. Medicare Advantage appeals follow the federal Medicare process described above.

How I help

I'm a licensed agent, not a lawyer, and I can't decide an appeal or promise an outcome. What I can do is read the denial letter with you, work out which deadline is running, tell you whether a fast appeal fits, and list what your doctor's office should send. If denials keep coming up with the same plan, that is also worth weighing at the next enrollment window. Medicare Advantage in the Capital Region and Medicare Advantage versus Medigap in New York cover how prior authorization and networks differ between the two. Ask me, no fee.

We do not offer every plan available in your area. Currently we represent 10 organizations which offer 81 products in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options. 1-800-MEDICARE (TTY 1-877-486-2048) is available 24 hours a day, 7 days a week. Insurers' legal names and home offices: carriers page.