How to appeal a Medicare Advantage denial.

The person enrolled in the plan, or someone acting for them. For care that hasn’t happened yet, the treating doctor can also ask on the enrollee’s behalf, as long as the doctor tells the enrollee.

Start with the denial notice, and follow its directions for where and how to send the appeal.

There are two ways to have the standing to appeal for someone else.

• Be appointed. Your parent signs Form CMS-1696, Appointment of Representative, or an equivalent written notice, and you sign it too. Plans must accept the form and can’t insist on their own. Ask the plan’s member services where to send it; the number is on the member ID card.
• Be authorized under state law. A court-appointed guardian, someone with durable power of attorney, or a health care proxy doesn’t need the form, but has to show the legal papers.

An appointment lasts one year from the day both of you have signed, and it covers any appeal filed in that year. Until a valid form is on file, the plan sends everything to your parent, not to you.

Put the appeal in writing and send it where the notice says. Include:

• Your parent’s name, address and the Medicare Number on their Medicare card.
• The items or services you’re appealing, the dates of service, and why you disagree.
• Your name and proof that you can act for them, if you’re the one appealing.
• Anything that makes the case stronger, such as a letter from the doctor.

Before you write, ask the doctor or the provider for any information that would make the appeal stronger.

A standard appeal for care you’re waiting for gets an answer within 30 days. If waiting that long could seriously jeopardize your parent’s life, health or ability to regain maximum function, ask for a fast appeal instead. The plan then has 72 hours.

If a doctor makes the request, or supports it and says the wait could cause that harm, the plan must make it fast. Fast appeals aren’t available for bills for care already received.

If the plan refuses to speed it up, it moves the appeal to the standard 30 days and must tell you in writing within three days. You can ask again with a doctor’s support.

• Care you’re waiting for: 30 days.
• A bill for care already received: 60 days.
• A Part B drug: 7 days.
• A fast appeal: 72 hours.

For care and services, the plan can take up to 14 more days in some cases, for example to get records from a doctor outside its network. It has to tell you in writing, and why.

When the denial said the care wasn’t medically necessary, the appeal must be decided by a physician with the right expertise who had no part in the first decision.

If the plan keeps its decision, in whole or in part, or misses its deadline, it must send the case to an independent reviewer that works for Medicare. You don’t file anything. What happens at the independent review.