How to Start a Medicare Appeal: Taking the First Steps

Receiving a Medicare denial can be a frustrating and confusing experience, but it’s not the end of the road. Your right to appeal is firmly established in federal law and regulations. The key to a successful appeal is starting with a well-prepared first step.

This guide will walk you through the immediate actions you need to take after receiving a denial notice to begin your appeal.

Step 1: Understand Your Denial Notice

The most important document you have is the official denial notice itself. Do not discard this document.

  • For Original Medicare (Parts A and B): You will receive a Medicare Summary Notice (MSN). This notice lists all your claims and will include a reason code for any denial. It also tells you where and how to file your first appeal.

  • For Medicare Advantage (Part C) or Part D: You will receive a formal denial letter or an Explanation of Benefits (EOB) from your plan. This notice will explain the reason for the denial and provide instructions for how to file your first appeal with the plan.

Step 2: Note Your Appeal Level and Deadline

The first level of appeal is different depending on your type of Medicare coverage. It is crucial to use the correct process and meet the deadline.

  • Original Medicare (Parts A and B): Your first appeal is a Redetermination request filed with the specified Medicare contractor. You must file this request within 120 calendar days from the date on your MSN.

  • Medicare Advantage (Part C) and Part D: Your first appeal is a Reconsideration request (for Part C) or Redetermination request (for Part D) filed directly with your plan. You must file this request within 60 calendar days from the date on your denial notice.

Step 3: Gather Your Evidence and File Your Appeal

Your first appeal request needs to clearly explain why you disagree with the denial. You have the right to submit evidence, so a well-supported claim is a strong one.

  • Submit in Writing: You should file your appeal in writing. You can use an official form (like the CMS-20027 for a Redetermination) or write a detailed letter.

  • Include Key Documents: Always include a copy of your denial notice, relevant medical records, and a letter of medical necessity from your doctor if available.

  • Mail with Proof: It is essential to mail your request with a method that provides proof of delivery, as the deadline is based on when the entity receives your request.

Starting a Medicare appeal may seem daunting, but by following these clear steps, you can confidently take control of the process.