How to appeal a Medicare denial for your parent, step by step
By the Folkswise team · Updated · 7 min read · How we write these guides
A denied claim isn't the final word. Your parent has the right to appeal, and many appeals succeed when the right paperwork is sent on time. The process depends on whether your parent has Original Medicare or a Medicare Advantage plan.
First, check whether it's really a denial
- Call the provider's billing office. Many “denials” are coding or paperwork mistakes the provider can fix by resubmitting the claim.
- Read the reason on the Medicare Summary Notice or plan EOB. It often says exactly what was missing.
- Ask your parent's doctor whether they'll write a short letter explaining why the service was medically necessary. It's often the most useful document in an appeal.
Original Medicare: the first two levels
Level 1 is a “redetermination” by the company that handles Medicare claims in your parent's area. File by the date printed on the Medicare Summary Notice (generally 120 days from receiving it). You can follow the MSN's instructions (circle the items you disagree with, explain why, sign, and mail it to the address shown), or use Form CMS-20027, the Medicare Redetermination Request.
Level 2 is a “reconsideration” by an independent reviewer. If Level 1 says no, you have 180 days after getting that decision to ask for it. The decision letter explains how.
If the answer is still no, there are further levels: a hearing with an Administrative Law Judge, the Medicare Appeals Council, and federal court. Some of these need a minimum dollar amount in dispute, which changes each year.
Medicare Advantage: ask the plan first
In a Medicare Advantage plan, the first step is asking the plan for a “reconsideration” within 65 days of the date on the plan's denial notice. The notice explains how to ask, and the plan's member services line can help.
If waiting could seriously harm your parent's health, ask for a fast (expedited) appeal. Plans generally must decide those within 72 hours. If the plan still says no, the case is usually sent to an independent reviewer automatically.
Being discharged too soon?
If your parent is in the hospital and you think they're being discharged too soon, there's a separate, faster appeal. The hospital must give your parent a notice called “An Important Message from Medicare about Your Rights.” It lists the phone number of the reviewer to call, and you should call right away, before your parent leaves.
Tips that help
- Send copies, never originals. Keep a copy of everything you send, with the date.
- Use a delivery method you can track, so you can prove you met the deadline.
- Write your parent's name and Medicare number on every page.
- If you're filing for your parent, include the Appointment of Representative form (CMS-1696).
- Your State Health Insurance Assistance Program (SHIP) helps with appeals for free: shiphelp.org.
Common questions
- How long do you have to appeal a Medicare denial?
- In Original Medicare, by the date on the Medicare Summary Notice, which is generally 120 days from when your parent got it. In a Medicare Advantage plan, within 65 days of the date on the plan's denial notice.
- Can I file a Medicare appeal for my parent?
- Yes. Your parent can appoint you as their representative with Form CMS-1696, which you include with the appeal.
- Do Medicare appeals cost anything?
- No, there's no fee to file. Free help is available from your State Health Insurance Assistance Program (SHIP).
- What if the appeal is denied?
- The decision letter explains the next level and its deadline. In Original Medicare, you have 180 days after a Level 1 decision to ask for a Level 2 reconsideration by an independent reviewer.