What is an appeal?
When we make a decision about what services we will cover or how we’ll pay for them, we let you know. Usually we will send you an Explanation of Benefits (EOB) statement or a letter explaining our decision about a pre-authorization request. An appeal is a request from a member, or an authorized representative, to change a decision we have made about:
Who is a member?
A member is:
Who can appeal?
The member can appeal, or a representative the member chooses, including an attorney or, in some cases, a doctor.
How to appeal
You can appeal a decision online; in writing using email, mail or fax; or verbally. You must appeal within 60 days of getting our written decision. Be sure to include any other information you want considered in the appeal. If the decision was after the 60-day timeframe, please include the reason you delayed filing the appeal.
Appropriate staff members who were not involved in the earlier decision will review the appeal. Once that review is done, you will receive a letter explaining the result.
You can also get information and assistance on how to submit an appeal by calling the Customer Service number on the back of your member ID card.
To appeal online today
You can send your appeal online today through DocuSign.
To appeal by email, mail or fax
Use the appeal form below. Instructions are included on how to complete and submit the form. You can also get information and assistance on how to submit a written appeal by calling the Customer Service number on the back of your member ID card.
To appeal verbally
Call the phone number on the back of your member ID card. Customer Service will help you with the process.
To request or check the status of a redetermination (appeal)
Call 1 (866) 749-0355.
For member appeals that qualify for a faster decision, there is an expedited appeal process.
An appeal qualifies for the expedited process when the member or physician feels that the member's life or health would be jeopardized by not having an appeal decision within 72 hours. We will accept verbal expedited appeals. Please contact the Medicare Appeals Team at 1 (866) 749-0355 or submit the appeal in writing and stating you need a “fast,” “expedited,” or “hot" review, or a similar notation on the paperwork.
If requested, we will supply copies of the relevant records we used to make our initial decision or appeal decision for free. Those documents will include the specific rules, guidelines or other similar criteria that affected the decision.
For any appeals that are denied, we will forward the case file to MAXIMUS Federal Services for an automatic second review. MAXIMUS Federal Services is a contracted provider hired by the Center for Medicare and Medicaid Services (also known as CMS) and has no affiliation with us. MAXIMUS will review the file and ensure that our decision is accurate. If MAXIMUS disagrees with our decision, we authorize or pay for the requested services within the timeframe outlined by MAXIMUS.
If you have any questions about your member appeal process, call our Customer Service department at the number on the back of your member ID card.
People with a hearing or speech disability can contact us using TTY: 711.
Para asistencia en español, por favor llame al teléfono de Servicio al Cliente en la parte de atrás de su tarjeta de miembro.
Para humingi ng tulong sa Tagalog, pakitawagan ang numero ng telepono ng Serbisyo sa Kostumer (Customer Service) na nakasulat sa likod ng inyong kard bilang miyembro.
Diné kʼehjí áká'eʼyeedgo, t'áá shǫǫdí áká anídaalwoʼí bi béésh bee haneʼé ninaaltsoos bee atah nílínígíí bineʼdę̀ę̀ bikááʼ.