Medical appeals
If we make a coverage decision and you are not satisfied with this decision, you can "appeal" the decision. An appeal is a formal way of asking us to review and change a coverage decision we have made.
When you make an appeal, we review the coverage decision we have made to check to see if we were following all of the rules properly. Your appeal is handled by different reviewers than those who made the original unfavorable decision. When we have completed the review we give you our decision.
If we say no to all or part of your Level 1 Appeal, you can go on to a Level 2 Appeal. The Level 2 Appeal is conducted by an independent organization that is not connected to us. (In some situations, your case will be automatically sent to the independent organization for a Level 2 Appeal. If this happens, we will let you know. In other situations, you will need to ask for a Level 2 Appeal.) If you are not satisfied with the decision at the Level 2 Appeal, you may be able to continue through additional levels of appeal.
For more information please visit the medicare.gov website's detailed description of the Medicare Advantage appeals process.
An appeal is a formal way of asking us to review and change a coverage decision we have made. For more information on making an appeal about your medical care, see Chapter 9 of the Evidence of Coverage (EOC): What to do if you have a problem or complaint (coverage decisions, appeals, complaints).
Please contact Customer Service at 1-833-574-6031 or TTY 711 (the TTY number requires special telephone equipment and is only for people who have difficulties with hearing or speaking). We are available from 8 a.m. to 8 p.m. (MST) on these days:
- October 1 - March 31 - seven days a week
- April 1 - September 30 - Monday through Friday
Fax: 1-208-519-3964
Write
P.O. Box 9018
Boise, ID 83707-9018
You or your authorized representative (someone you name to act for you), may file an appeal. Your representative can be a relative, friend, advocate, attorney, doctor, or someone already appointed by the State to act on your behalf. Call Customer Service if you need help naming a representative.
You must send us a statement naming the person you want to act for you by using the Appointment of Representative form. You and your authorized representative must sign, date and deliver the statement.