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Appealing a Medicare Claim Decision

Why, when and how to challenge a denial of benefits

Filing an initial appeal if you have a Medicare Advantage (or Part C) health plan


Medicare Advantage plans, which are administered by private insurance companies, are required by Medicare to have an appeals process by which you can get a redetermination if your plan denies you a service or benefit you think should be covered.

If you disagree with the decision, you can request an independent review.

If that decision is not in your favor, you can proceed up the appeals levels to an administrative law judge, the Medicare Appeals Council and federal court.

In addition, Medicare Advantage companies must give patients a way to report grievances about the plan and the quality of care they receive from providers in the plan.

If you have a Medicare Advantage plan, look at your plan materials or contact the plan administrator for information about filing a grievance or an appeal. For more details, see the Medicare publication “Your Medicare Rights and Protections” or "Medicare Advantage Plans and Medicare Cost Plans: How to File a Complaint (Grievance or Appeal)."

Next: Appealing a Medicare Part D claim decision. >>

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