How to Appeal a Medicare Advantage Denial in Tennessee: Steps, Deadlines, and What to Include

Quick answers

How can I appeal a Medicare Advantage denial?

Start with your plan's denial notice, which explains why and how to appeal. The first appeal is called a reconsideration, and you, your representative or your doctor can request it. You usually have 65 days from the date on the notice to file.

What should I include in a Medicare Advantage appeal?

Include your name, address, Medicare number, the item or service you're appealing, the date of service and why you disagree. If someone represents you, add their information and proof they can act for you. Supporting documents, like a doctor's note, can strengthen your case.

How long does a Medicare Advantage plan have to decide an appeal?

For a standard appeal before you get care, 30 days. For payment of care you already got, 60 days. For certain Part B drugs, 7 days. A fast appeal, used when waiting could seriously harm your health, must be decided within 72 hours.

What are the five steps in the Medicare appeals process?

Level 1 is reconsideration by your plan. Level 2 is an Independent Review Entity, which gets your case automatically if the plan says no. Level 3 is the Office of Medicare Hearings and Appeals, Level 4 the Medicare Appeals Council, and Level 5 federal district court. A licensed agent at The Jordan Insurance Agency can review this with you by phone or video.

In this episode

Learn the exact steps to appeal a Medicare Advantage denial in Tennessee, including deadlines, what to include, and how the five appeal levels work. Billy Jordan of The Jordan Insurance Agency breaks it down.

• Step-by-step guide to appealing a Medicare Advantage denial in Tennessee
• Key deadlines, required information, and supporting documents explained
• What happens at each of the five Medicare appeal levels

Source: Appeals in Medicare health plans (medicare.gov)

Billy Jordan is a licensed insurance agent (NPN 8699876) with The Jordan Insurance Agency, with an office in Nashville, Tennessee. Voices in this episode are AI-generated, including Billy's, from a script reviewed and approved by Billy Jordan, a licensed insurance agent. General education only, not advice for your specific situation.

Not affiliated with or endorsed by Medicare or any government agency.

Tanya (AI host): I just got a denial from my Medicare Advantage plan here in Tennessee—how do I appeal, and what steps do I actually have to take? If you’re confused by the process, stick around, because it’s more than just sending a letter.

Tanya (AI host): Welcome to Smart Coverage. Real Advice., the insurance podcast from The Jordan Insurance Agency. I'm Tanya, your host, and I'm here with Billy Jordan, a licensed insurance agent and the president of The Jordan Insurance Agency.

Billy Jordan: Glad to be here, Tanya. A quick disclaimer: we're not affiliated with or endorsed by Medicare or any government agency, and this is general education, not advice for your situation. Now, let's get into it.

Tanya (AI host): So Billy, someone in Tennessee gets a denial from their Medicare Advantage plan. What’s the very first thing they need to do if they want to appeal?

Billy Jordan: The first step is to look at the denial notice you received from your plan. That notice will tell you exactly why something was denied and give you instructions on how to start your appeal. According to the medicare.gov article "Appeals in Medicare health plans," in Medicare Advantage, that first appeal is called a "reconsideration." You, your representative, or even your doctor can request it. And you usually have sixty-five days from the date on the denial notice to file that appeal.

Tanya (AI host): Sixty-five days—that's a pretty specific window. Is there certain information someone needs to include when they file?

Billy Jordan: Yes, and it’s important to be thorough. You’ll need your name, address, Medicare number, the item or service you’re appealing, the date of service, and why you disagree with the denial. If you have a representative, include their info and proof they’re allowed to act for you. Anything extra, like a doctor’s note, can really help make your case stronger.

Tanya (AI host): And if someone misses that sixty-five day deadline, are they out of luck?

Billy Jordan: If you file late, you need to explain why—maybe you were in the hospital or didn’t get the notice right away. You must include your reason for filing late in your appeal.

Tanya (AI host): What about if the service hasn’t happened yet—can a doctor help with the appeal?

Billy Jordan: Absolutely. If you’re appealing something you haven’t received, your doctor can file the reconsideration on your behalf, but they must notify you they’re doing it. That’s especially helpful if you need care quickly.

Tanya (AI host): Speaking of needing care quickly, what if someone feels waiting could really hurt their health? Is there a way to speed things up?

Billy Jordan: Great question. According to medicare.gov, you can request what’s called a "fast" or "expedited" appeal. If your doctor agrees that waiting the normal thirty days could seriously harm your health or your ability to recover, you or your doctor can ask for this faster review. The plan then has to make a decision within seventy-two hours.

Tanya (AI host): That’s a lot faster than thirty days. Are there other timelines people should know about?

Billy Jordan: Yes. For a standard pre-service appeal, the plan has thirty days to decide. If it’s about payment for something you already got, they have sixty days. For certain Part B drugs, it’s seven days. The plan can extend these timeframes by up to fourteen days, but only if they need more information and it’s in your best interest. If they do that, they have to let you know in writing.

Tanya (AI host): So let’s say the plan still says no after that first appeal. What happens next?

Billy Jordan: If your plan denies your appeal fully or partially, they have to automatically send it to what’s called an Independent Review Entity, or IRE. This is level two. The IRE reviews your case from scratch. The timelines are pretty similar: thirty days for pre-service, sixty for payment, and seventy-two hours for a fast appeal.

Tanya (AI host): And if the IRE still doesn’t decide in your favor, can you keep going?

Billy Jordan: Yes, you can. You have sixty days from the IRE’s decision to request a level three appeal, which is handled by the Office of Medicare Hearings and Appeals, or OMHA. At this stage, there’s usually a minimum dollar amount your case has to meet—in twenty twenty-six, it’ll be two hundred dollars. You can ask for a hearing before an Administrative Law Judge, or even request a review just based on the paperwork if you don’t want a hearing.

Tanya (AI host): So it’s not just paperwork anymore—you could actually speak to a judge?

Billy Jordan: That’s right. Most level three hearings are done by phone or video, but in some cases, they can be in person. You get to explain your side, and the judge will review the facts independently. If you want to skip the hearing, you can submit a form to waive it, and the judge or an attorney will make a decision based on your records.

Tanya (AI host): If OMHA still decides against you, is there another step?

Billy Jordan: There is. That’s appeal level four, where you can ask for a review by the Medicare Appeals Council. You’d follow the instructions in the judge’s decision letter. You can fill out a form or submit a written request, and you’ll need to include the details of what you’re appealing and why.

Tanya (AI host): And if someone still disagrees after the Appeals Council?

Billy Jordan: That’s the fifth and final level: a judicial review in federal district court. For that, the amount in dispute has to meet a minimum—one thousand nine hundred sixty dollars in twenty twenty-six. You have sixty days from the date of the Appeals Council’s decision to request this, and the decision letter will explain how.

Tanya (AI host): What’s a common mistake people make when they try to appeal?

Billy Jordan: One big mistake is missing the deadline to file the appeal, or not including enough information—like forgetting to say exactly what you’re appealing, or why you disagree. Another is not sending extra supporting documents, like a doctor’s note, which can really help.

Tanya (AI host): Three things to remember. One, always check your denial notice for instructions and file your appeal within sixty-five days. Two, include all the details and any supporting documents to strengthen your case. Three, if you disagree with a decision, you can move up through five levels of appeals, each with its own process and deadlines.

Tanya (AI host): For a personalized look at your situation, book a free thirty-minute chat with Billy and his team at thejordaninsuranceagency.com/podcast.

Billy Jordan: I'm Billy Jordan with The Jordan Insurance Agency. Until next time, take care.

Tanya (AI host): Thanks for listening to Smart Coverage. Real Advice. from The Jordan Insurance Agency.