Navigating Medicare Advantage Plan Denials

Medicare Advantage vs Original Medicare

Medicare Advantage (MA) plans are private insurance that provides Medicare benefits. They can have:

• Narrower networks
• Prior authorization requirements
• Different covered services
• Utilization management that Original Medicare doesn't use

MA plans deny claims at higher rates than Original Medicare, according to OIG reports.

Five Levels of MA Appeals

1. Organization Determination — initial coverage request/decision
2. Reconsideration — reviewed by an independent review entity (IRE) — Maximus
3. ALJ Hearing — Administrative Law Judge (for claims meeting dollar threshold)
4. Medicare Appeals Council — review of ALJ decision
5. Federal District Court — judicial review

Key Differences from Commercial Insurance

• Level 2 goes directly to INDEPENDENT reviewer (Maximus), not the plan
• CMS provides specific coverage criteria
• Medicare Rights Center offers free assistance: 1-800-333-4114
• SHIP counselors in every state provide free help

Tips for MA Appeals

• Request expedited review if treatment delay would harm your health
• The 72-hour expedited timeline is strictly enforced for MA plans
• Switching to Original Medicare during open enrollment bypasses MA restrictions
• SHIP counselors are specifically trained in Medicare appeals — use them