Family & support
A coverage decision you disagree with: your next steps
A denial can feel final. Start by reading what was decided and which response process applies. You do not need to solve the whole issue in one phone call.
You can appeal certain Medicare coverage or payment decisions. Use the instructions and deadline on your notice. The process differs for Original Medicare, Medicare health plans, and drug plans.
Identify the decision
Find the service, item, medicine, or payment in question. Read the reason for the decision. Keep the full notice, not just the first page. Ask the sender to explain unfamiliar wording and identify the applicable appeal process.
Protect the deadline
Record the due date and where the response must go. Some notices about services ending describe a fast appeal with a short deadline. Follow those instructions promptly. A routine customer service conversation should not be assumed to pause an appeal deadline.
Ask the provider for supporting information
Your provider or supplier may have information that strengthens the appeal. Ask what documentation is relevant and how it will be submitted. Keep copies of what you send and proof of submission. Avoid sending unrelated private records.
Get appropriate help
SHIP offers free local Medicare counseling. A trusted person may be appointed as your representative through the applicable process. Ask what authorization is required. A broker can help you understand whom to contact, but cannot promise that a denial will be overturned.
Read the response and next instructions
An appeal decision should explain the outcome and any next level available. Keep the new deadline with the response. If the situation concerns immediate medical needs, speak with your treating team about care while the coverage issue is being addressed.
Make it useful
Your next step checklist
Use this here, or print it for your next conversation. Your checks stay on this page only.