Because we denied your request for coverage of (or payment for) medical care, you have the right to ask us for an appeal of our decision. You have 60 days from the date of our Notice of Denial of Medical Coverage to ask us for an appeal.
You or your doctor may ask us for an appeal on your behalf. If you want another individual (such as a family member or friend) to request an appeal for you, that individual must be your representative. You may download and complete the
Note: You will need to mail or fax separately the documentation showing the authority to represent the Enrollee (a competed Appointment of Representative Form CMS-1696 or a written equivalent) if it was not submitted at the organization determination level. For more information on appointment a representative, contact our plan or 1-800-Medicare.
Medical Coverage you are requesting:
Important Note: Expedited Decisions