Appeals and Grievances in Medicare Advantage Plans

When something goes wrong with your Medicare Advantage plan, you have two main options: appeals and grievances. Knowing which one to use can make the difference between getting your problem solved and hitting a dead end.

Use an Appeal When:

• Your plan denies coverage for a surgery, test, or treatment your doctor recommends
• Your plan stops paying for services you're currently receiving (like skilled nursing care)
• Your plan refuses to cover a prescription drug
• Your plan won't approve prior authorization for a procedure
• Your plan denies payment for services you already received

Appeals challenge specific coverage decisions. They have strict deadlines but also give you the right to take your case all the way to federal court if necessary.

Use a Grievance When:

• You're unhappy with your plan's customer service
• Appointment wait times are too long
• A provider or plan staff member treats you rudely
• Your plan's communications are confusing or misleading
• You're dissatisfied with how your appeal was handled

Grievances address quality of care and customer service issues. They're easier to file but stay within your plan's internal review process—you can't take them to an outside reviewer.

Why the Difference Matters

Filing the wrong type of complaint can cost you important rights. If your plan denies your MRI and you file a grievance instead of an appeal, you'll miss the 65-day deadline to challenge that decision. Always file an appeal for coverage denials, even if you're also frustrated with how you were treated.

The Five Levels of Medicare Advantage Appeals

Medicare Advantage appeals follow a clear path with five possible levels of review. Most cases get resolved at the first or second level, but knowing the full process helps you understand your rights.

Level 1: Plan Reconsideration

This is where your appeal starts—with your plan itself. You have 65 days from the denial notice to file your appeal (this was extended from 60 days in January 2025). Your plan must respond within:

• 30 days for standard appeals
• 72 hours for expedited appeals (when waiting could seriously harm your health)

Here's the encouraging news: plans overturn their own denials about 82% of the time. That means four out of five appeals succeed right at this first level.

Level 2: Independent Review Entity (IRE)

If your plan denies your Level 1 appeal, it automatically goes to an independent reviewer—someone with no connection to your plan. The IRE has the same timeframes: 30 days for standard reviews, 72 hours for expedited ones. This outside review often catches mistakes your plan made in the initial denial.

Levels 3-5: Federal Review

If your appeal is still denied and meets certain dollar thresholds, you can take it to:

• Level 3: Administrative Law Judge hearing ($190 minimum in 2025)
• Level 4: Medicare Appeals Council review
• Level 5: Federal district court ($1,840 minimum)

Most appeals resolve well before reaching these levels, but knowing they exist gives you leverage in earlier discussions with your plan.

Special Rules: Fast-Track Appeals and Quality Improvement Organizations

Some situations get special protection through fast-track appeals. These apply when you're:

• In a hospital and facing discharge you think is too early
• In a skilled nursing facility with services being terminated
• Receiving home health care that's being stopped
• Getting hospice care that's ending

For these situations, you can contact your area's Quality Improvement Organization (QIO) for immediate review. Fast-track appeals through QIOs give you extra protection and faster decisions when you need them most.

How to File a Winning Appeal

Success in Medicare Advantage appeals isn't about luck—it's about preparation and strategy. Here's what works:

Gather Strong Documentation

The most successful appeals include:

• Detailed letter from your doctor explaining why the service is medically necessary
• Test results and medical records that support the request
• Treatment history showing what you've tried before
• Research or guidelines that support your doctor's recommendation

Address Each Denial Reason

Your denial notice will list specific reasons why your plan said no. Your appeal needs to respond to each one directly. If they said the treatment is "not medically necessary," provide evidence that it is. If they called it "experimental," show that it's an accepted treatment.

Meet All Deadlines

This can't be stressed enough—missed deadlines can cost you your right to appeal. File within 65 days of your denial notice, and respond quickly to any requests for additional information.

Consider Getting Help

You can appoint someone to help with your appeal—a family member, friend, or professional advocate. This representative can handle all communications with your plan and make decisions on your behalf.

Real Stories: When Appeals Work

Patricia's Chemotherapy Coverage: When Patricia's Medicare Advantage plan denied coverage for chemotherapy her oncologist recommended, she felt overwhelmed. But her Level 1 appeal succeeded within two weeks. The key? Her appeal included comprehensive medical records showing cancer progression, her doctor's detailed explanation of why this specific treatment was necessary, and references to her plan's own coverage rules for cancer care.

Robert's Wheelchair Appeal: Robert's plan initially denied coverage for a custom wheelchair, saying a standard one would work fine. His first appeal was denied, but the Independent Review Entity at Level 2 overturned the decision. The winning strategy: detailed assessments from physical and occupational therapists showing exactly why he needed the custom equipment, plus documentation that standard wheelchairs had failed to meet his needs.

These stories share common themes: comprehensive medical documentation, direct responses to denial reasons, and persistence when the first answer was no.

Why So Few People Appeal (And Why You Should)

Despite the high success rates, most people never appeal Medicare Advantage denials. Common reasons include:

"I didn't know I could" - Many people think plan decisions are final. They're not.

"It seems too complicated" - The process has steps, but it's designed to be accessible to everyone.

"I don't want to rock the boat" - Federal law prohibits plans from retaliating against members who file appeals.

"I can't afford a lawyer" - You don't need one. Most appeals succeed without legal representation.

The truth is, if your doctor says you need care and your plan says no, you owe it to yourself to appeal. The statistics are on your side, and the process exists to protect your rights.

Recent Changes That Strengthen Your Rights

Medicare Advantage appeals have gotten stronger in recent years thanks to new regulations:

Extended Deadlines

Starting in 2025, you now have 65 days to file appeals instead of the previous 60 days. This gives you more time to gather documentation and get help with your case.

Better Coverage Standards

Plans must now follow Medicare's official coverage rules, not their own more restrictive policies. This means many services that were wrongly denied in the past should now be covered.

Enhanced Fast-Track Rights

The expanded fast-track appeal system now covers more situations and gives you additional ways to challenge service terminations quickly.

Transparency Requirements

Plans must now publicly share their coverage criteria and prior authorization requirements, making it easier to understand why decisions are made and how to challenge them.

When to Call for Backup: Getting Outside Help

Sometimes you need extra support to navigate the appeals process. Here are your options:

Medicare Direct

Call 1-800-MEDICARE (1-800-633-4227) for immediate help understanding your appeal rights and getting connected to resources.

State Health Insurance Assistance Program (SHIP)

Every state has free SHIP counselors who can help you complete appeals, explain coverage rules, and even attend hearings with you. They're completely independent from insurance companies.

Medicare Beneficiary Ombudsman

When plans are unresponsive or you're facing systematic problems, the Medicare Beneficiary Ombudsman can investigate and escalate issues to higher authorities.

Legal Aid

For complex or high-value appeals, organizations like LawHelp.org can connect you with free or low-cost legal assistance.

How Medicare Advantage Appeals Differ from Original Medicare

If you're familiar with Original Medicare appeals, Medicare Advantage works differently in important ways:

Timeframes: You have 65 days to appeal in Medicare Advantage versus 120 days in Original Medicare, but you get faster decisions—30 days versus 60 days.

Who Reviews: Medicare Advantage plans review their own Level 1 appeals, while Original Medicare uses independent contractors from the start.

Fast-Track Options: Both systems offer fast-track appeals, but the rules and organizations involved are different.

Understanding these differences helps you navigate your specific situation more effectively.

Filing Grievances: When It's Not About Coverage

Not every problem requires an appeal. Grievances handle operational and quality issues that don't involve coverage decisions:

Common Grievance Issues:

• Long wait times for specialist appointments
• Rude treatment by plan staff or providers
• Problems with plan communications or websites
• Billing issues that aren't coverage disputes
• General dissatisfaction with plan operations

How to File:

Grievances are typically easier than appeals. You can usually:

• Call your plan's customer service line
• Submit complaints through your plan's website
• Send written grievances by mail or email

Plans must respond to grievances within 60 days and investigate quality-of-care issues thoroughly.

Your Rights Throughout the Process

Whether filing appeals or grievances, you have important rights that plans must respect:

Right to Representation

You can choose anyone to help with your case and make decisions on your behalf with proper authorization.

Right to Information

You can review all documents your plan used to make coverage decisions and submit additional evidence at any time.

Right to Continued Coverage

In certain situations (like fast-track appeals), your coverage continues while the appeal is pending.

Right to Fair Treatment

Plans cannot discriminate against you for filing complaints or seeking your rightful benefits.

Making the Most of Your Medicare Advantage Plan

Appeals and grievances are your safety net, but here are ways to prevent problems before they start:

Understand Your Plan: Review your Evidence of Coverage document to know what's covered and what requires prior authorization.

Use In-Network Providers: Staying in-network helps avoid unexpected denials and costs.

Get Prior Authorization: When required, get approval before receiving services to avoid later payment disputes.

Keep Good Records: Maintain copies of all communications with your plan and providers.

Know Your Rights: Understanding appeals and grievances helps you act quickly when problems arise.

How a Solace Advocate Can Help Navigate Appeals and Grievances

When facing a Medicare Advantage denial or plan problem, you don't have to handle it alone. Solace advocates specialize in Medicare and understand exactly how to make the system work for you.

Solace Advocates Can Help You:

Determine the Right Path ForwardWe'll help you understand whether you need to file an appeal or grievance, ensuring you use the right process and don't miss important deadlines.

Gather Winning DocumentationOur advocates work with your healthcare providers to collect and organize the medical records, test results, and physician statements that make appeals successful.

Handle All the PaperworkFrom completing forms to writing compelling appeal letters that address every denial reason, we take care of the administrative burden so you can focus on your health.

Navigate Complex DeadlinesWith different timelines for appeals, grievances, and fast-track options, we ensure nothing gets missed and all filings happen on time.

Communicate with Your PlanWe serve as your dedicated advocate, handling all communications with your Medicare Advantage plan and following up to keep your case moving.

Escalate When NecessaryIf your first appeal is denied, we'll take it to the Independent Review Entity and beyond if needed. We don't give up on cases that should succeed.

Connect You with Additional ResourcesWhen appropriate, we'll help you access Quality Improvement Organizations, SHIP counselors, or other resources that can strengthen your case.

Provide Ongoing SupportUnlike calling a customer service line where you speak to someone different each time, your Solace advocate stays with you throughout the entire process.

Why Solace Advocacy Makes a Difference

Our advocates understand that Medicare Advantage appeals aren't just about paperwork—they're about getting you the care you need to stay healthy and independent. We've seen firsthand how the right documentation and strategic approach can turn denials into approvals.

With our 54% success rate for overturning denied claims and deep understanding of Medicare rules, we know how to present your case in the strongest possible light. More importantly, we know how to translate complex Medicare regulations into clear action steps that protect your rights and get results.

Whether you're facing a coverage denial for surgery, battling prior authorization requirements, or frustrated with your plan's customer service, a Solace advocate can help you navigate the system successfully. Because when it comes to your healthcare, you deserve someone in your corner who knows the rules and isn't afraid to fight for your rights.

This article is for informational purposes only and should not be substituted for professional advice. Information is subject to change. Consult your healthcare provider or a qualified professional for guidance on medical issues, financial concerns, or healthcare benefits.

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