Medicare Advantage denied your claim
You have 65 days. Here’s how the appeal works.
Appeal or grievance? Appeal a denied claim or payment. File a grievance about bad service. They’re separate tracks.
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1. First, read the denial notice
Every denial must come in writing and say why. The reason decides your next move:
- “Not medically necessary” — ask your doctor for a letter explaining why you needed it. That letter wins more appeals than anything else.
- “No prior authorization” — if an in-network provider skipped the step, you generally shouldn’t be billed beyond your copay. Call the plan.
- “Out of network” — check whether it was an emergency or urgent care, which plans must cover anywhere in the U.S.
- You paid and want reimbursement — send the plan your itemized bill and proof of payment. A refusal is a decision you can appeal.
2. The five appeal levels
| Level | How fast it’s decided | Minimum in dispute |
|---|---|---|
| 1. Plan reconsideration | 30 days for care, 60 days for payment, 72 hours if urgent | None |
| 2. Independent review | Same timeframes | None |
| 3. Judge hearing | Months | $200 |
| 4. Appeals Council | Months | No added minimum |
| 5. Federal court | Varies | $1,960 |
Most disputes end at level 1 or 2. Ask for an expedited appeal if waiting could seriously harm your health — a doctor’s request makes it automatic.
3. Grievances: problems that aren’t a denial
A grievance is a complaint about how the plan treated you: hours on hold, a rude representative, a provider’s conduct, trouble getting an appointment. File it with the plan within 60 days of the problem; the plan generally must answer within 30 days.
A grievance won’t overturn a denied claim. If money or coverage is at stake, file the appeal — and add a grievance separately if the service was also bad.
4. Who to call
| Call | When |
|---|---|
| Your plan (number on your card) | Always first — ask for the denial reason and appeal form |
| 1-800-MEDICARE (1-800-633-4227) | The plan isn’t following the rules, or you want to file a complaint about it |
| Your SHIP | Free one-on-one help with an appeal or with switching plans — find yours at shiphelp.org |
5. For federal retirees: the FEHB exit
If Medicare Advantage keeps failing you, the way out depends on what you did with FEHB:
- You suspended FEHB: you can generally re-enroll at FEHB Open Season, or sooner if your Medicare Advantage coverage ends involuntarily. See suspending FEHB for Medicare Advantage.
- You cancelled FEHB: you generally can’t return.
- Leaving Medicare Advantage: switch plans or return to Original Medicare during Medicare Open Enrollment (October 15 to December 7) or the Medicare Advantage Open Enrollment Period (January 1 to March 31).
For a claim under your FEHB plan rather than Medicare Advantage, the process is different; Warrior Insure covers it in appealing a denied FEHB claim.
6. Frequently asked questions
How long do I have to appeal a Medicare Advantage claim denial?
You have 65 days from the date on the plan’s denial notice to ask the plan for a reconsideration. A request about a service you have not received yet is decided within 30 days, a payment request within 60 days, and an urgent request within 72 hours.
What happens if my Medicare Advantage plan denies my appeal?
The plan must automatically send your case to an Independent Review Entity, an outside reviewer that is not part of the plan. You do not have to file anything for that second level.
What is the difference between an appeal and a grievance?
An appeal challenges a decision about coverage or payment, such as a denied claim. A grievance is a complaint about how the plan treated you, such as long waits, rude service or a provider’s conduct. File a grievance with the plan within 60 days of the problem; the plan generally must respond within 30 days.
When should I call 1-800-MEDICARE or a SHIP?
Call 1-800-MEDICARE (1-800-633-4227) to file a complaint about the plan or when the plan is not following the rules. Your State Health Insurance Assistance Program gives free, unbiased one-on-one help with appeals and with choosing or leaving a plan.
Can a federal retiree go back to FEHB if Medicare Advantage isn’t working?
If you suspended FEHB to join a Medicare Advantage plan, you can generally re-enroll in FEHB during Open Season, or sooner if your Medicare Advantage coverage ends involuntarily. If you cancelled FEHB instead of suspending it, you generally cannot return.