A June 2026 report from the Department of Health and Human Services (HHS) Office of Inspector General highlights just how valuable taking that next step can be. Investigators found that when patients or their healthcare providers formally appealed an initial Skilled Nursing Facility denial, the decisions were overturned in favor of the patient the vast majority of the time- including a 97% reversal rate for care requests processed by certain major review contractors.
If you or a loved one receives a denial notice, don’t let the paperwork discourage you. Work with your care team to file an appeal right away; the data shows that taking full advantage of the appeals process is well worth the effort.
File an appeal by following the exact instructions provided in your plan’s written denial notice and Evidence of Coverage. Submit a written request- known as a “reconsideration” -to your Medicare Advantage plan within 65 calendar days of your denial notice, and be sure to include supporting documentation from your doctor.
The Appeals Process Step-by-Step:
1. Review Your Denial Letter
Your Medicare Advantage company is legally required to send you a written notice explaining exactly why they are denying your coverage or payment. This letter contains crucial information, including deadlines and the specific forms you need to fill out.
Your Medicare Advantage company is legally required to send you a written notice explaining exactly why they are denying your coverage or payment. This letter contains crucial information, including deadlines and the specific forms you need to fill out.
2. Gather Your Documents
Build a stronger case by collecting documentation to support your appeal:
Build a stronger case by collecting documentation to support your appeal:
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- Any written materials from your doctor explaining why the care, service, or medication was medically necessary.
- Your Medicare Beneficiary Identifier (MBI) or plan membership number.
- A completed Appointment of Representative Form if someone else (like a family member or attorney) is filing on your behalf.
3. Submit the Level 1 Appeal (Reconsideration)
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- Standard Appeal: File this request in writing (via mail or fax) within 65 days of the date on your initial denial notice. Your plan must provide a decision within 30 days for pre-service requests or 60 days for post-service requests.
- Expedited Appeal: If your health is at immediate risk, ask for a fast appeal. You can do this over the phone or in writing. If approved, your plan is required to make a decision within 72 hours.
4. Escalate to Further Levels
If the Medicare Advantage plan denies your Level 1 appeal, your case is automatically forwarded to a Medicare-contracted Independent Review Entity (IRE). You do not need to do anything to initiate this transfer; the plan must do it for you.
If the Medicare Advantage plan denies your Level 1 appeal, your case is automatically forwarded to a Medicare-contracted Independent Review Entity (IRE). You do not need to do anything to initiate this transfer; the plan must do it for you.
Helpful Resources
- Medicare Appeals Publications: Read the official Medicare Appeals Guide for comprehensive details.