Medicare Advantage reconsideration request
Ask your Medicare Advantage plan to review its denial again. The plan's appeal is called a reconsideration, and an outside reviewer sees the case if the plan says no.
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- A template, not legal advice
This one is for a specific kind of coverage
It is written for the coverage tagged above. If you have a different kind (for example Medicare or Medicaid instead of a job-based or individual plan), it may cite the wrong rules. Check what kind of coverage you have and use the letter written for it.
When to use this, and what it is not
When to use this. When your Medicare Advantage plan (Part C) denied a service, item or payment. The safest reading of the deadline is 65 calendar days from the date on the denial notice. The rule is 60 days after you receive it, with receipt presumed 5 days after the date on the notice. Check the date on your notice, which controls. If your notice is about ending hospital, nursing facility, home health or rehabilitation care, the deadline is much shorter: see the next steps.
This is a template, not legal advice. Read it, change anything that is not true for you, and send it only when you are satisfied. Your notice and your plan document control.
Fill in the letter
Your letter
[Your name] [Your address]
13 November 2026
[Name and address of your Medicare Advantage plan's appeals office, from your denial notice]
Re: Medicare Advantage reconsideration request Plan: [Name of the health plan] Member ID: [Member ID] Claim or reference number: [Claim or reference number]
To whom it may concern:
I am asking my Medicare Advantage plan, [Name of the health plan], to reconsider its decision dated [Date on the denial notice]. A reconsideration is the plan's first level of appeal. My member identification (ID) number is [Member ID] and the plan's reference or claim number is [Claim or reference number].
The plan refused [The care or drug that was denied], provided or requested on [Date of the care] by [Doctor, hospital or pharmacy]. I disagree with that decision. My reasons are: [Why you disagree with the decision]
I ask that you: 1. Have the reconsideration decided by someone who was not involved in the first decision. If the denial was based on medical necessity, I ask that a physician with appropriate expertise decide it. 2. Send me your decision and the reasons in writing. 3. If you uphold your denial in whole or in part, send my case file to the Independent Review Entity, the outside reviewer under contract with Medicare, as the rules require, and tell me the date you sent it.
I understand the plan must decide within 30 calendar days for a service I have not yet received, 60 calendar days for a request for payment, and 7 calendar days for a Part B drug (a drug given in a doctor's office or outpatient setting), unless a fast decision applies.
Enclosures: 1. Copy of the plan's denial notice 2. Letter from your doctor and medical records 3. Any bills or receipts, if the denial is about payment
Sincerely, [Your name]
Before you send it
Send it to the appeals address or fax number on your denial notice, with proof of the date. An expedited request can be made by phone, using the number on the notice. A standard request must be in writing unless the plan accepts oral requests. Your doctor may also file after telling you.
What to enclose
- Copy of the plan's denial notice
- Letter from your doctor and medical records
- Any bills or receipts, if the denial is about payment
What happens next
- Your deadline is 60 calendar days after you receive the denial, with receipt presumed 5 days after the date on the notice. Treat it as 65 calendar days from the date on the notice. Late filing is allowed for good cause. Check the date on your notice, which controls.
- If the plan upholds its denial, or misses its deadline, it must send your case to the Independent Review Entity without you asking. The entity is C2C Innovative Solutions, Inc. for requests from 1 May 2026; MAXIMUS Federal Services handles requests received through 30 April 2026.
- One exception: if the plan dismisses your request, for example as late or invalid, you must ask the Independent Review Entity in writing to review the dismissal within 60 calendar days of the dismissal notice (the Centers for Medicare & Medicaid Services (CMS) describes this as 65 days from the date on the notice).
- If your notice is about ending hospital care, ask the quality improvement organization named on it for a review no later than the day you leave the hospital. For skilled nursing, home health or rehabilitation services ending, ask by noon of the day after you receive the notice.
- A complaint about service, such as rudeness or waiting time, is a grievance, not an appeal. A grievance does not take the place of this request.
- State Health Insurance Assistance Programs give free, one-on-one Medicare counseling and are not connected to any insurance company. Find yours at shiphelp.org or call 877-839-2675. You can also call 1-800-MEDICARE (1-800-633-4227).
- If you are writing for someone else, tick "I am writing for someone else". The plan may require its own authorization form. See the letter "Name someone to act for you".