Understanding Medicare Appeals: What to Do If Your Coverage is Denied

If Medicare denies coverage for a health service or item you need, you still have options. Both Original Medicare and Medicare Advantage plans offer formal appeal processes that allow you to request a review of the decision. Knowing your rights—and the steps to take—can make all the difference.

You can download the full Medicare Minute handout with complete details here.

Before You File an Appeal

Before starting an appeal, take a moment to gather information and confirm whether the denial was made in error. According to the handout, “Call your health care provider to see if they made a billing mistake that caused the denial.” If no error occurred, your provider may be able to help you with the appeal or even submit one on your behalf.

It’s also important to contact Medicare or your Medicare Advantage plan to understand the reason for the denial. Your appeal letter should directly address that reason. Be sure to read all denial notices carefully—these documents include instructions and deadlines you must follow.

How to Appeal an Original Medicare Denial

If you are enrolled in Original Medicare, start by reviewing your Medicare Summary Notice (MSN). The handout explains that you should circle the denied service and complete the shaded section at the end of the MSN. Then mail your appeal to the Medicare Administrative Contractor (MAC) within 120 days of the date on your MSN.

How to Appeal a Medicare Advantage Denial

Medicare Advantage plans have two different appeal pathways depending on whether you have already received the service:

• If you were denied coverage before receiving the service or item: Request a written decision from your plan called a Notice of Denial of Medical Coverage. Follow the instructions on the notice and submit your appeal within 60 days. Your plan must respond within 30 days.
• If you were denied coverage for a service or item you already received: Follow the instructions on the denial notice and file your appeal within 60 days. Your plan must respond within 60 days.

If You Miss the Appeal Deadline

Even if you miss the deadline, you may still be able to appeal if you can show good cause. The handout notes examples such as receiving the notice at the wrong address, being given incorrect information by Medicare, or being unable to manage paperwork due to illness. “If you think you have a good reason for not appealing on time, send your appeal as you normally would and include a clear explanation of why your appeal is late.”

Where to Get Help

You don’t have to navigate the appeals process alone. Your local SHIP and SMP programs are here to support you:

• SHIP (State Health Insurance Assistance Program) Toll-free: 1‑866‑413‑5337 |Email: shineinfo@aaaswfl.org |Website: www.floridashine.org
• SMP (Senior Medicare Patrol) Toll-free: 1‑866‑413‑5337 |Email: shineinfo@aaaswfl.org |Website: www.floridashine.org

These programs can help you understand your denial, strengthen your appeal, and spot potential errors or fraud.

The Medicare Rights Center is the author of portions of the content in these materials but is not responsible for any content not authored by the Medicare Rights Center. This document is supported by the Administration for Community Living (ACL), U.S. Department of Health and Human Services (HHS) as part of a financial assistance award totaling $3,000,000 with 100% funding by ACL/HHS. The contents are those of the author(s) and do not necessarily represent the official views of, nor an endorsement, by ACL/HHS, or the U.S. government.