Medicare appeals in Arizona

Start with your notice

Every Medicare denial comes with a written notice that explains the decision, how to appeal and the deadline. Which notice you get depends on your coverage:

• Original Medicare: the Medicare Summary Notice (MSN), mailed every few months or available in your Medicare.gov account. It shows which claims were denied and gives the address of the Medicare contractor that processes claims in Arizona.
• Medicare Advantage plan: a written denial notice from the plan, and the Explanation of Benefits for payment decisions.
• Part D or a Medicare plan with drug coverage: a coverage determination notice from the plan. If the pharmacy can't fill a prescription, ask the pharmacist for the notice explaining how to contact your plan.

Keep copies of everything, and ask your doctor for a letter explaining why you need the service or drug. A doctor's support is often what wins an appeal. You can name someone to act for you, such as a family member, with Medicare's Appointment of Representative form (CMS-1696).

Original Medicare: the five levels

Levels 3 and 5 apply only if the amount in dispute is at least a minimum that Medicare sets each year; the level 5 minimum is much higher than the level 3 minimum. You may be able to combine claims to reach it. Medicare.gov publishes the current amounts.

Medicare Advantage appeals

With a Medicare Advantage plan, the plan makes the first decisions, and the steps have different names:

1. Organization determination. The plan's decision on whether it will cover a service or pay a claim, including prior authorization. If waiting could seriously harm your health, you or your doctor can ask for a fast decision.
2. Reconsideration (level 1). If the plan says no, you, your representative or your doctor can ask the plan to reconsider within 65 days. A standard decision on a service you haven't received comes within 30 days, a payment decision within 60 days, a Part B drug decision within 7 days, and a fast decision within 72 hours.
3. Independent Review Entity (level 2). If the plan keeps its denial, it must send your case automatically to an independent reviewer. You don't have to file anything.
4. Levels 3 to 5. Same as Original Medicare: a hearing, the Medicare Appeals Council, then federal court, with the same yearly minimum amounts.

If you are dual eligible and in a D-SNP that is aligned with your AHCCCS plan, the plan's notice explains how Medicare and AHCCCS appeals are handled together. For AHCCCS-only services, follow the instructions on the AHCCCS notice. See AHCCCS and Medicare.

Part D drug appeals

1. Coverage determination. Ask your plan to cover a drug, including an exception (to cover a drug not on its formulary, waive a step-therapy or quantity rule, or charge a lower cost-sharing tier). For an exception, your prescriber must send a statement explaining the medical reason. The plan generally decides within 72 hours, or 24 hours if you ask for a fast decision because waiting could seriously harm your health.
2. Redetermination (level 1). If the plan says no, ask for a redetermination within 65 days of the date on the denial notice. The plan decides within 7 days (or 14 days for a payment request), or 72 hours for a fast appeal.
3. Independent Review Entity (level 2). Unlike Medicare Advantage medical appeals, you must ask for this review yourself, within 60 days of the plan's decision.
4. Levels 3 to 5. A hearing, the Medicare Appeals Council and federal court, each requested within 60 days, with yearly minimum amounts for levels 3 and 5.

Fast appeals: hospital discharge and services ending

When covered care is ending, a separate, faster process applies. In Arizona, these appeals go to Commence Health (formerly Livanta), the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for Arizona and the rest of Medicare's Region 9, at 1-877-588-1123.

The BFCC-QIO also reviews complaints about the quality of care you received from a doctor, hospital or other provider under Medicare.

IRMAA appeals (higher premiums based on income)

If your income from two years ago was above the first IRMAA limit ($109,000 for an individual or $218,000 for a married couple filing jointly, for 2026 premiums), Social Security adds an income-related amount to your Part B and Part D premiums. Because brackets are cliffs, a dollar over a limit raises the whole amount. Social Security, not Medicare, makes this decision, and there are two ways to challenge it:

• Life-changing event (Form SSA-44). If your income has dropped because of marriage, divorce or annulment, the death of a spouse, stopping or reducing work, the loss of income-producing property, or the loss or reduction of a pension, ask Social Security to use a more recent year's income. This is common in the first years after retirement.
• Reconsideration. If the tax information Social Security used is wrong, or you disagree with the decision for another reason, you can ask for a reconsideration within 60 days of the notice.

Estimate your bracket with our IRMAA calculator, and contact Social Security at 1-800-772-1213 or an Arizona Social Security office to file.

Grievances: complaints that aren't appeals

If your problem isn't a coverage or payment decision, such as long waits for appointments, trouble reaching customer service, or how you were treated, file a grievance with your Medicare Advantage or Part D plan. You generally have 60 days from the problem to file, and the plan must respond within 30 days, or faster if the complaint is about a refusal to give you a fast decision. You can also tell Medicare about a problem with a plan at 1-800-MEDICARE or with the complaint form on Medicare.gov.

Complaints to the Arizona Department of Insurance (DIFI)

The Arizona Department of Insurance and Financial Institutions regulates insurance companies and licenses insurance agents in Arizona. DIFI can't change a Medicare coverage decision, which goes through the federal appeals above, but you can file a complaint with DIFI about:

• A Medigap (Medicare Supplement) company that won't pay a claim or that you think broke Arizona insurance law.
• An insurance agent's conduct, such as misleading sales practices or enrolling you in a plan without your permission. (Report these to 1-800-MEDICARE as well.)
• Problems with other insurance products sold to people with Medicare, such as hospital indemnity or dental policies.

DIFI's consumer services line is 602-364-2499, and complaints can be filed online at difi.az.gov.

If you suspect fraud

A charge you don't recognize on your MSN or Explanation of Benefits may be a billing error or fraud. The Arizona Senior Medicare Patrol (1-800-432-4040), part of the DES Division of Aging and Adult Services, helps people with Medicare check suspicious charges and report fraud. You can also report fraud to 1-800-MEDICARE or the HHS Office of Inspector General at 1-800-HHS-TIPS (1-800-447-8477). More numbers are on our Arizona Medicare contacts page.

When an appeal isn't the answer

If a plan keeps denying a drug or service you need, or a doctor you rely on leaves its network, it may make sense to change plans during an enrollment period you qualify for. A licensed insurance agent with Benefits Life can explain the plans from the companies they work with and when you can switch, at no cost to you: call (602) SENIORS (602-736-4677), TTY 711. For the appeal itself, follow the instructions on your notice and call 1-800-MEDICARE with questions.

Sources

• Medicare.gov — Appeals in Original Medicare
• Medicare.gov — Appeals in Medicare health plans
• Medicare.gov — Appeals in Medicare drug plans
• Medicare.gov — Fast appeals
• Medicare.gov — Filing complaints
• eCFR — 42 CFR Part 423 Subpart M, Part D grievances, coverage determinations and appeals
• eCFR — 42 CFR Part 422 Subpart M, Medicare Advantage grievances and appeals
• CMS contact directory — Livanta (now Commence Health), BFCC-QIO for Arizona
• Social Security — Form SSA-44, Medicare Income-Related Monthly Adjustment Amount, Life-Changing Event
• Social Security — Lower your IRMAA
• Arizona Department of Insurance and Financial Institutions
• HHS Office of Inspector General — Report fraud

Frequently asked questions

How long do I have to appeal a Medicare denial?

For Original Medicare, file the first appeal by the date on your Medicare Summary Notice, generally 120 days after you receive it. For a Medicare Advantage or Part D plan denial, file within 65 days of the date on the plan's notice. Later levels generally must be requested within 60 days, except the second Original Medicare level, which allows 180 days.

Can I stay in the hospital while I appeal my discharge?

Yes, if you ask Arizona's BFCC-QIO, Commence Health (1-877-588-1123), for a review no later than your planned discharge day, following the directions on the Important Message from Medicare. You can generally stay while it reviews your case without paying for the extra days, other than any usual deductibles or coinsurance.

How do I appeal IRMAA?

IRMAA is decided by Social Security, not Medicare. If your income dropped because of a life-changing event such as retirement, the death of a spouse or divorce, ask Social Security for a new decision with Form SSA-44. If you think the tax information Social Security used is wrong, you can request a reconsideration.

What is the difference between an appeal and a grievance?

An appeal asks a plan or Medicare to change a decision about coverage or payment. A grievance is a complaint about something else, such as long waits, rude staff or a plan's customer service. You generally file a grievance with your plan within 60 days of the problem.

Can the Arizona Department of Insurance help with my Medicare appeal?

DIFI can't overturn a Medicare coverage decision, which follows the federal appeals process. It does handle complaints about insurance companies and licensed agents in Arizona, including Medigap claim problems and agent sales practices.