You have the right to appeal if you disagree with a coverage or payment decision made by Medicare, your Medicare Advantage plan or your Medicare prescription drug plan (Part D). Learn where to find appeals information and how to get in touch with us if you need help understanding the appeals process.
What you can appeal
You can file a complaint with the Office of the Insurance Commissioner (OIC) if you disagree with a coverage or payment decision made by your Medicare supplement (Medigap) plan. We regulate these plans for the state of Washington.
You can file an appeal with Medicare, which is regulated by the federal government, if your plan denies a request:
- For a health care service, supply, item or prescription drug that you think you should be able to get
- For payment of a health care service, supply, item or prescription drug you already received
- To change the amount you must pay for a health care service, supply, item or prescription drug
You can also appeal if Medicare or your plan stops providing or paying for all or part of a health care service, supply, item or prescription drug you think you still need.
You can contact our Statewide Health Insurance Benefits Advisors (SHIBA) volunteers for help with understanding the appeals process and what your rights are.
If you decide to appeal
It is important that you verify your claims information is correct on your Medicare Summary Notice or Explanation of Benefits forms. These should detail the care you have received for the past three months on Original Medicare or Medicare Advantage.
Ask your doctor, health care provider or supplier for any information that may help your case. See your plan materials or contact your insurer for details about your appeal rights. You can usually find your plan's contact information on your plan membership card. You can also search for your plan’s contact information on Medicare’s website.
The appeals process has five levels. If you disagree with the decision made at any level of the process, you can generally go to the next level. At each level, you'll be given instructions in the decision letter on how to move to the next level of appeal.
It's very important to follow the appeals timeline and provide the necessary documentation to support your appeal.
More information on the appeals process
These resources on Medicare’s website can help you navigate the appeals process: