What you can appeal 

If you disagree with your Medicare supplement (Medigap) plan's decision on coverage or payment, you can file a complaint with us. We regulate these plans for Washington state. 

You can file an appeal with Medicare, which the federal government regulates, 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 how much you need to 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. 

For help with understanding the appeals process and your rights, contact our Statewide Health Insurance Benefits Advisors (SHIBA) volunteers. 

If you decide to appeal 

Make sure your Medicare Summary Notice or Explanation of Benefits forms have the correct information about your claim. These should explain 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. 

Ask your doctor, health care provider or supplier for any information that may help your case. For details about your appeal rights, see your plan's documents or contact your insurer. 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 a decision at any level, you can generally go to the next one. At each level, the decision letter will give you instructions on moving to the next level. 

When you appeal, it's very important to provide documents and information on time.

More information on the appeals process 

Medicare’s website has resources to help you with appeals: