ABA Family Legal Guide

The Rights of Older Americans

Health and Long-Term Care Benefits

Medicare

What if I disagree with a Medicare decision? How can I appeal?

You have the right to appeal all decisions regarding service coverage or the amount Medicare will pay on a claim. If your claim has been denied in whole or in part, it is usually a good idea to appeal, especially if the basis of denial is unclear. A surprisingly high percentage of denials are reversed on appeal. In any case, the appeal will make clear the reason for the denial.

Medicare Parts A, B, and D have different procedures for appealing and several steps in the appeal process. Procedures are also somewhat different depending upon whether you are in Original Medicare or in a Medicare Advantage Plan. After the initial levels of review, if your dispute hasn't been resolved, all part of Medicare include the option of a hearing before an administrative law judge and even a review by a federal court if sufficient amounts of money are at stake.

Always be conscious of time limits for filing appeals. You may lose your rights if you wait too long. You may want to get assistance with your appeal from a legal services office or a private lawyer, particularly if large medical bills are involved. Nonlawyer volunteers and nonlawyer staff members of legal service programs help a number of people with appeals without charging fees.