If you are dissatisfied with a health care decision made by your Medicare Advantage (MA) plan, you can file an appeal or — in some situations — a grievance. Here, we’ve outlined your 4 options.
Topics on this page:
- Option 1: Appeals Process
- Option 2: Expedited Appeals Process
- Option 3: Fast-Track Appeals Process
- Option 4: Grievances
After receiving your request to provide or pay for a service or item you think should be covered or continued, your Medicare Advantage (MA) plan responds with an organization determination. If the plan decides not to pay for or continue a service or item, it must inform you in writing and include:
- Reason(s) for denying the service or item; and
- Instructions on how to appeal the organization determination.
If a written notice is not given within 14 days for a requested service or item, or within 30 days for a requested payment, you may treat the lack of response as a denial and request reconsideration by the plan, which is the first step in the appeals process.
The MA appeals process can include 5 steps, described below:
Step 1: Reconsideration by Plan
If you are not satisfied with the MA plan’s decision, you have 60 days to file a written request for reconsideration. You can also submit a copy of your medical records and a letter of support from your doctor (if you’ve requested one). After receiving your reconsideration request, the MA plan must issue a decision within 30 days for service issues, and within 60 days for payment issues. If the MA plan does not reverse its decision, it must forward your appeal to an Independent Review Entity (IRE) within 24 hours.
Step 2: Reconsideration by Independent Review Entity (IRE)
The IRE contracts with Medicare to conduct external reviews, which must occur within the following timeframes:
- Expedited reviews: 72 hours to 17 days
- Service denials: 30 to 44 days
- Payment denials: 30 to 60 days
After completing its review, the IRE must send a written copy of its determination to both you and Medicare. The notice must describe the basis for the IRE’s determination and, if the IRE finds that the MA plan was correct in denying Medicare coverage, it must inform you of your right to an Administrative Law Judge (ALJ) hearing when the amount in question is at least $160 (in 2019).
California’s IRE is MAXIMUS, Inc..
Step 3: Administrative Law Judge (ALJ) Review
If your claim is denied by the IRE, you have the right to a fair hearing before an ALJ if the amount in dispute is at least $160 (in 2019). You have 60 days from the date of the IRE decision to file a request. The ALJ has 90 days to issue a decision, but this timeframe can be extended for various reasons, such as submission of new evidence or request for an in-person hearing.
ALJ hearings take place at the federal Department of Health and Human Services, which only has 4 offices with ALJs. As a result, ALJ hearings are commonly held by videoconference, phone, or in-person (at the ALJ’s discretion, if you can show good cause as to why the hearing should be held in person).
Note: You should consider seeking legal advice before requesting an ALJ review.
Step 4: Medicare Appeals Council (MAC)
If the ALJ denies your claim, you have 60 days to request an MAC review. Most MAC reviews are not conducted in person. Instead, the MAC reviews the relevant documents and issues a decision. The MAC has 90 days to issue a decision, but this timeframe can be extended for several reasons, including submission of new evidence.
Note: You should consider seeking legal advice before requesting an MAC review.
Step 5: Federal Court
If the MAC rules against you and the amount in dispute is at least $1,630 (in 2019), you can file a lawsuit in federal district court within 60 days. You will probably need legal assistance, and the process will likely be time-consuming.
An expedited appeal is a faster way to address your request for services. Many medical conditions require immediate action when a service has been denied or terminated. Patients who would be at risk of serious health deterioration or death are typical candidates for an expedited appeal.
You, a doctor or your representative can request this type of appeal. If a doctor requests an expedited appeal, the MA plan must review the case within 72 hours. This doctor is not required to be your primary care physician or a member of the MA plan. If you or your representative request the expedited appeal, the MA plan will review it and either approve or deny it. If approved, the appeal will occur within 72 hours. If denied, the appeal will go through the standard 14-day appeals process.
You may also file a grievance for a denied request for an expedited appeal. See Option 4: Grievances.
You have the right to request a fast-track appeal through California’s Quality Improvement Organization (QIO), Livanta if:
- You feel you are being discharged from a hospital before you are ready
- Your MA coverage is about to end for services in a skilled nursing facility (SNF), home health agency (HHA), hospice or comprehensive outpatient rehabilitation facility (CORF).
A fast-track appeal differs from an expedited appeal because an outside organization — HSAG — reviews your appeal instead of the MA plan. A fast-track appeal is typically used by people being discharged from the facilities listed above.
At least 2 days before your coverage ends for a given service, your MA plan must give you and your provider an Important Message of Non-Coverage notice. This notice must include:
- The date Medicare coverage will end (clearly typed at the top of the page; must be at least 2 days after the date you receive notice).
- The date you will be responsible for the cost of your care (must be at least 2 days after the date you receive notice).
- How to get more information about the reason the MA plan is terminating your coverage for this service.
- How to exercise your right to use this fast-track appeals process.
Your MA plan must also send you a more detailed notice of non-coverage that specifically explains why it discontinued your coverage and list the relevant Medicare rule that justifies the decision. You will not receive this notice until after you request an appeal.
To request a fast-track appeal, follow the instructions on the Important Message of Non-Coverage notice, and make your request by noon of the day following the notification. You can also contact Livanta online or by phone at 1-877-588-1123 or 1-855-887-6668 (TDD-hearing impaired).
Once you request a fast-track appeal, your MA plan is required to send your medical records to Livanta within 1 day. Livanta then has 1 day to decide on your fast-track appeal. If Livanta agrees with you, it may set a new service termination date, or require your MA plan to give you another Important Message of Non-Coverage notice when it discontinues coverage in the future. If Livanta agrees with the MA plan, you will be responsible for the cost of your care starting the day Livanta issues its decision.
All Medicare Advantage (MA) plans are required to have internal grievance procedures, which apply only when the formal appeals procedures do not and/or you’ve been denied a request for an expedited appeal. These written procedures must include specific timeframes (described below) as well as instructions on how to file a grievance.
Some examples of grievances include:
- Complaints about services in an optional supplement benefit package
- Complaints regarding waiting times, physician behavior and demeanor, adequacy of facilities and other member concerns
- Involuntary disenrollment situations
If you file a grievance, your MA plan must notify you of its decision with 30 days of receipt of the grievance. Your MA plan may extend this timeframe by up to 14 days if you request the extension to gather more supportive information, or if the plan justifies that an extension is in your interest. If your plan extends the deadline, it must notify you in writing of the reasons for the delay.
If you file a grievance in writing, your MA plan is required to send you a written response. If you file a grievance by phone, your plan may respond in writing or by phone, unless you specifically request a written response.
If you file a quality of care grievance (in writing or by phone), your MA plan must send you a written response that includes information on your right to file a written complaint with your Quality Improvement Organization (QIO). Your MA plan must cooperate with the QIO to resolve the complaint.
In California, the QIO is Livanta.