A refusal is not the end of the matter. Medicare has a formal appeals process with several levels, independent review beyond the first stage, and deadlines that work in your favour if you meet them.
Denials are overturned more often than people expect. A significant share of first refusals are paperwork outcomes rather than clinical judgements, and they change when somebody supplies the missing piece.
This guide is about doing that.
First: what kind of refusal is it?
The route depends on what was refused and under what.
Original Medicare, a claim refused after the fact. You appeal via the Medicare Summary Notice.
An Advantage plan, a service refused. You appeal to the plan, and if it upholds the refusal it must automatically forward the case to an independent reviewer.
A drug plan, a medication refused. You start with a coverage determination request, then a redetermination.
All three then follow the same ladder upwards.
The single most important thing
Note the date of the refusal, and act inside the deadline.
Every level has a time limit counted from the notice. Missing one is the most common way an appeal that would have succeeded does not happen. If you are close to a deadline, file something — even a short letter saying you are appealing — and supply detail afterwards.
The ladder
Level one — redetermination. The plan, or the Medicare contractor, looks again. Your prescriber’s supporting statement carries the most weight here.
Level two — independent review. An organisation with no relationship to the plan reconsiders. For Advantage denials that are upheld, this happens automatically; for others you request it.
Level three — an administrative law judge. A hearing, usually by telephone or video. There is a minimum amount in dispute to reach this level, set annually.
Level four — the Medicare Appeals Council.
Level five — federal district court.
Most matters end at level one or two. It is worth knowing the ladder continues, because it changes how a first refusal feels.
Fast versus standard
If waiting for a standard decision would seriously jeopardise your health or your ability to regain function, you can ask for an expedited decision. If your prescriber supports the request, the plan must use the shorter timescale.
Ask for it when it is warranted. Do not ask routinely — it is a real mechanism and it works better for everybody when it is used properly.
What actually persuades
Appeals succeed on clinical specificity, not on indignation.
Get your prescriber involved on day one. A supporting statement from the treating clinician is the most powerful single document in the process. Telephone the practice and ask for the person who handles appeals and prior authorisations — every practice has one.
Say what was tried and what happened. “Tried the preferred alternative in March, discontinued after two weeks because of X” does more than a page of general argument.
Name the contraindication. If the plan’s preferred alternative is unsuitable because of another condition or another medication, say so plainly.
Attach the evidence. Notes, test results, the pharmacy’s written notice, prior correspondence.
Keep it to the point. The reviewer is deciding one question. Answer that question.
Practical mechanics
Put everything in writing, even when you also telephone. Note the date, the time and the name of everybody you speak to.
Keep a copy of every document you send. Send anything important by a method that gives you proof of delivery.
If somebody is helping you — a family member, a friend — the plan will need an authorised representative form before it will discuss your case with them. Complete it early. Being told at the deadline that your daughter cannot be told anything is a bad afternoon.
Where to get help, free
Your State Health Insurance Assistance Program. Counsellors help with appeals as a matter of routine, at no charge, with nothing to sell. Ohio, Kentucky and Indiana each run one.
1-800-MEDICARE, answered around the clock, TTY 1-877-486-2048.
Medicare.gov publishes the current forms, deadlines and instructions for every level. That is the authoritative source, and it is where you should check a deadline rather than relying on any web page including this one.
A Medicare Advocacy organisation or legal aid for complex or high-value cases.
Two special cases
Hospital discharge you believe is too early. There is a specific fast-track process, and you must use it immediately — the notice you are given on the ward explains how. It is separate from the ordinary ladder and the timescales are measured in hours.
Skilled nursing, home health or hospice ending. Similar fast-track rights apply when services are being terminated. The notice you receive sets out how to ask for an immediate review.
In both cases the right exists only if you use it straight away. If a parent is being discharged and it feels wrong, say so before they leave, not afterwards.
What we do, and do not do
We are insurance advisers. We are not lawyers and we do not represent people in appeals.
What we will do is tell you an appeal exists, tell you the deadline is short, and point you at the State Health Insurance Assistance Program, which does this properly and free. If we have ever placed a plan for you, telephone us anyway — we will help you find the right number and read the notice with you.
The one thing not to do is nothing. The deadline is the only part of this process that is truly unforgiving.
General information, not advice
This guide describes how Medicare generally works. It is not advice about your situation, and rules, dates and figures change — verify anything that matters to a decision against Medicare.gov,1-800-MEDICARE, or your State Health Insurance Assistance Program, all of which are free.
Rights and rules vary by state; this describes Ohio, Kentucky and Indiana. Clearview Medicare Advisers LLC is not connected with or endorsed by the United States government or the federal Medicare program.
Not sure how this applies to you?
Tell us your birthday and whether you are still working. That is usually enough for us to say which periods apply to you and by when. No charge and no obligation.
