MA plans deny prior authorizations and claims at higher rates than traditional Medicare. Many of those denials are wrong — and reversible. We can help you fight back.
Medicare Advantage plans have their own rules and appeal processes. Here's what we see most often.
Your plan won't approve the procedure, surgery, or medication your doctor recommended.
Many denials are overturned on appeal.
Your plan is cutting off skilled nursing facility coverage before you're ready to leave.
You have the right to appeal and request continued coverage.
Your plan denied coverage for in-home nursing, therapy, or aide services you need.
Home health denials can often be successfully appealed.
You were surprise-billed for using an out-of-network provider you didn't choose.
There are protections against balance billing in many cases.
Your plan won't cover your medication and requires you to try cheaper alternatives first.
Exceptions and appeals are available for medical necessity.
Your plan is trying to terminate your coverage or involuntarily disenroll you.
You have appeal rights and can request a fair hearing.
Medicare Advantage has its own appeal process. We know how it works — and how to win.
We review your Medicare Advantage denial notice and tell you whether it's worth fighting — and exactly how to do it.
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Large case? Ask about our contingency option — you pay nothing upfront, we take 30% only if we win.
Medicare Advantage plans have their own appeal process. Here's what you're up against — and how we win.
Your Medicare Advantage plan denies your request for a service, medication, or continued coverage. This is called an "organization determination" or "coverage determination."
You request that your plan reconsider its decision. This is called a "reconsideration." Your plan reviews its own denial. This is where most appeals are won — if properly prepared.
If your plan still denies, an Independent Review Entity (not affiliated with your plan) reviews your case. This is a fresh set of eyes on your case.
If the IRE upholds the denial, you can request a hearing before an Administrative Law Judge (ALJ). This requires the amount in dispute to exceed certain thresholds.
Plans deny initially to discourage appeals. But when you submit a well-documented appeal with the right citations and evidence, many denials get overturned. That's where we come in.
Common questions about MA denials and appeals.
Traditional Medicare (Parts A and B) is run by the federal government and allows you to see any provider who accepts Medicare. Medicare Advantage (Part C) is private insurance that replaces traditional Medicare. MA plans have their own networks, rules, and appeal processes. When you have MA, your plan — not Medicare — makes coverage decisions and handles appeals.
MA plans profit by managing care and limiting costs. They have financial incentives to deny requests that traditional Medicare would approve. However, these denials are often overturned on appeal — especially when properly documented and challenged. Studies show that when appeals are filed, many denials are reversed.
You typically have 60 days from the date on your denial notice to file an appeal. For ongoing care (like skilled nursing), you may be able to request an expedited (fast) appeal. Don't wait — missing the deadline means losing your right to appeal.
In some cases, yes. If you're currently receiving care that's being terminated (like home health or skilled nursing), you may be able to request "continued coverage" while your appeal is pending. This is called a "fast track appeal" and must be requested quickly. We can help you navigate this.
If you have an urgent healthcare need, you can request an expedited (fast) appeal. MA plans must decide expedited appeals within 72 hours. If your health is at risk, make this clear in your appeal request. Your doctor's support letter documenting medical necessity is crucial.
Not for the first two levels of appeal. Most MA denials are resolved at Level 1 (plan reconsideration) or Level 2 (independent review). These don't require legal representation. For Level 3+ (Administrative Law Judge), a lawyer or advocate becomes more valuable. We handle Levels 1-2; for Level 3+, we can connect you with attorneys who specialize in Medicare.
You can switch plans during Medicare Open Enrollment (October 15 – December 7) each year. However, switching plans shouldn't be your only option — if your plan wrongfully denied care, you have the right to appeal and potentially get that care covered. Appeals can result in faster resolution than waiting for open enrollment.
Don't let your MA plan's denial stand unchallenged. Many denials are wrong — and many are reversible. Let us review your case.
You typically have 60 days to appeal. Don't wait — the sooner you act, the better.
The denial letter or notice from your plan tells us a lot about your case. Have it handy when you contact us.
We'll review your denial notice and tell you whether an appeal makes sense — at no cost.
Call us to discuss your Medicare Advantage denial. We understand the process.
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