Appeal
Get a fast decision when health is at risk
Ask for an expedited appeal when waiting could seriously harm you, and keep treatment going where the rules allow.
Do this today
- Use the tool: Urgent appeal triage See whether you can ask for a fast decision, what your doctor must say, and who to call today.
- Read: How to get an expedited appeal 6 minute read. When waiting could seriously harm your health, you can ask for a fast appeal, decided in 72 hours or less, and ask for independent review at the same time. Here is how to ask and what your doctor can do.
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Put this step on My Plan
So you can come back to it, and keep your dates and calls in one place.
In brief
- A claim is urgent when waiting could seriously harm your life, your health or your ability to regain maximum function, or when your doctor says it would cause severe pain that cannot be managed without the care.
- If a physician who knows your condition says the claim is urgent, the plan must treat it as urgent. Plans that are not grandfathered must defer to your treating provider.
- An urgent appeal must be decided as soon as possible and no later than 72 hours. You can ask by phone, and you can ask for expedited external review at the same time.
More guides, tools and letters
More guides, tools, letters 13
Guides
- How to get an expedited appeal
When waiting could seriously harm your health, you can ask for a fast appeal, decided in 72 hours or less, and ask for independent review at the same time. Here is how to ask and what your doctor can do.
- Keeping treatment going during an appeal
When a plan has approved ongoing care and then cuts it short, the federal rules treat that as a denial with extra protections. Learn what to ask for so care does not stop while you appeal.
Tools
- Tool
Urgent appeal triage
See whether you can ask for a fast decision, what your doctor must say, and who to call today.
Letters and scripts
- Letter or script
Appeal my Medicaid plan's cut and keep my services going
Ask your Medicaid health plan to appeal a cut or ending of a service you already get, and to keep the service going while it decides. Ask within 10 calendar days of the notice, or before the change takes effect if that is later.
- Letter or script
Appeal: ending of ongoing treatment
Asks your plan to keep covering treatment it already approved while you appeal a decision to reduce or end it, and to decide before the benefit stops.
- Letter or script
Certification of urgency (for your clinician)
A short letter in a physician's voice stating that the standard time frame could seriously harm the patient, so the plan must treat the claim or appeal as urgent and decide within 72 hours. Every clinical statement is a blank for the physician to complete.
- Letter or script
Phone script: appeal to your Medicaid plan and keep services going
What to say when you phone your Medicaid health plan to appeal a cut or ending of services and keep them going during the appeal, what to ask for, what to do if told the provider must ask, and what to write down.
- Letter or script
Phone script: ask Medicare for a fast appeal when care is ending
What to say when you phone the Medicare quality reviewer to ask for a fast appeal because a hospital stay, nursing facility, rehabilitation or home health care is ending, and what to write down. For Original Medicare and Medicare Advantage.
- Letter or script
Request an expedited appeal
Asks your plan to decide an appeal as an urgent claim, within 72 hours, because waiting could seriously harm your health, and to contact your doctor.
- Letter or script
Request expedited external review
Ask for a fast independent review, decided within 72 hours, when waiting could seriously harm your health.
Checklists
- Checklist
Expedited appeal
How to ask your plan for a fast decision when waiting could seriously harm your health, and what to do if it says no.
Denial reasons
- Denial reason
Care is ending
Hospital, rehab, nursing home or home health care ending? Medicare: call the reviewer on your notice by noon the day after you get it, or 1-800-MEDICARE (1-800-633-4227). Medicaid or job-based plan: see What to send.
Programs and services
- Program or service
Beneficiary and Family Centered Care Quality Improvement Organizations: find yours
The Medicare contractors that handle fast appeals when hospital or other care is ending too soon, and complaints about the quality of care. Each state is assigned to one of two organizations.
From Centers for Medicare & Medicaid Services
Questions to keep handy
- What exactly was denied, and under which part of the plan?
- What is my deadline, and what is it counted from?
- Where and how do I send my request, and how will I prove it arrived?
- Who decides, and can I ask for a faster decision?
Not what you need? Find a person who can help, or search the whole site.