If Your Medicare Part C (Medicare Advantage) Claim Is Denied

Overview

If you are dissatisfied with a health care decision made by your Medicare Advantage (MA) plan, you have 4 options, which are outlined in this section:

  1. Argue your case through the appeals process
  2. Request an expedited appeal
  3. Request a fast-track appeal
  4. File a complaint through the internal grievance process

Your MA plan is required to include information on the appeals and grievance processes in its membership materials, which it must give to each enrollee.

You may appoint someone else — a family member, friend, caregiver or doctor — to be your representative in an appeal or complaint.

Note: If you are dissatisfied with a decision made by your MA plan about prescription drugs, you will need to follow a separate appeals process. See If Your Medicare Part D (Prescription Drug Coverage) Claim Is Denied.

See Your Options to Appeal.

Listen to our podcast on Medicare Part C Appeals – available in English and Spanish

Common Appeals Situations

Among other situations, you can appeal your MA plan’s decision if:

  • You are denied payment for using medical services received outside the MA plan in an emergency or urgent-care situation.
  • You are denied payment for using other medical services when you couldn’t get the care you needed within the MA plan.
  • Your MA plan refused or failed to give you treatment in a timely manner that you felt would otherwise be covered by original fee-for-service Medicare (in some cases, an expedited appealmay be in order).
  • Your MA plan discontinues services you believe are still medically necessary.

See Your Options to Appeal.