For Consumers

Appeal a Medicare coverage or payment decision

Disagree with a coverage or payment decision made by Medicare, your Medicare Advantage plan, or your Medicare prescription drug plan? You have the right to appeal if these plans deny one of these:

  • A request for a health care service, supply, item or prescription drug that you think you should be able to get
  • A request for payment of a health care service, supply, item or prescription drug you already received
  • A request to change the amount you must pay for a health care service, supply, item or prescription drug

You can also appeal if Medicare or your plan stops providing or paying for all or part of a health care service, supply, item or prescription drug you think you still need.

Before you decide to appeal

  • Verify your claims information is correct as stated on your Medicare Summary Notice or Explanation of Benefits.
  • Check with your medical provider's office and ask about your claim.

If you decide to appeal

Ask your doctor, health care provider or supplier for any information that may help your case. See your plan materials, or contact your insurer for details about your appeal rights. You can usually find your plan's contact information on your plan membership card.

The appeals process has five levels. If you disagree with the decision made at any level of the process, you can generally go to the next level. At each level, you'll be given instructions in the decision letter on how to move to the next level of appeal.

It's very important to follow the appeals timeline and provide the necessary documentation to support your appeal.

Resources for appealing