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Appealing a Medicare Claim Decision

Why, when and how to challenge a denial of benefits

by: Education & Outreach, from: AARP, Updated 2012

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.

Getting Help

To learn more about your appeal rights, visit Medicare.gov. To get help filing your appeal, contact your local State Health Insurance Assistance Program (SHIP).

If your Medicare Advantage plan provider does not respond to your request for an appeal, you can file a complaint or grievance with Medicare by calling 800-MEDICARE (800-633-4227). TTY users should call 877-486-2048.

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)."

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