My Medicare Advantage plan denied coverage for a specialist I need to see. What are my options now?

Question

Esther Miller · Accepted Answer

Your primary care physician may need to make the referral before its approved by your plan, especially if you have a HMO plan vs a PPO or HMO-POS plan where you can select specialists on your own instead of through your primary care provider. The other situation is the specialist you selected may not be in network. Again with HMO plans you always need to stay in network. With a PPO plan, you can choose a specialist who is not in network, but you will pay significantly more if you do. Check either with your agent or the customer service to find out what your options are to resolve this issue.

Answered by Esther Miller on April 7, 2025

Agent Licensed in WA

Answered by Esther Miller Medicare Insurance Agent

Michael Pyers · Answer

You can file an appeal with the plan.  If all else fails, you can contact the Dept of Insurance in your area.  Also, you can report the plan to CMS Quality Improvement Organization at 888-524-9900.

Joseph Peck · Answer

Was the specialist not in network? Also does your primary need to write a letter of exception to have it covered?

Steve Brauer · Answer

You have the right to an appeal and to request the reasoning behind the denial. I would have my agent discuss with the carrier the reason for the denial and possible alternatives.

Vachik Chakhbazian · Answer

your first step is to understand why the denial occurred and whether it's due to a network issue, lack of prior authorization, or other coverage limitations. Then, you can appeal the denial through the formal Medicare appeal process, you can consider switching to a different Medicare Advantage plan or exploring Original Medicare with a Medigap policy

Answered by Vachik Chakhbazian on April 22, 2025

Agent Licensed in CA, AL, AR & 22 other states

Answered by Vachik Chakhbazian Medicare Insurance Agent

Mike Henry · Answer

Find another one. You’ll have to get a new referral from your Dr. or ask Medicare   Call 1-800- Medicare for assistance

Randy Hill · Answer

If your Medicare Advantage plan said “no” to the specialist you need, don’t panic — you still have some options!

Here’s what to do:

1. Read the letter they sent. It tells you why they said no and how you can ask them to change their mind. That’s called an appeal.

2. You can appeal! Just write a note (or fill out a form) saying why you need this doctor. You usually have 60 days to send it in.

3. Ask your doctor for help. A letter from them saying why this specialist is important can make a big difference.

4. Need it fast? If your health might get worse by waiting, ask for a fast appeal. They’ll answer in 3 days or less.

5. Still no? You can appeal again and again. Don’t give up!

You can get free help from your local State Health Insurance Assistance Program (SHIP). They can help you fill out forms and explain everything. You can find your local SHIP at www.shiphelp.org.

Always save copies of everything — letters, forms, notes from your doctor — just in case you need them later.

Fran Lovelace · Answer

Your plan's website should have the process to file an appeal.  Your doctor's office can do it for you.

Ricky Gonzalez · Answer

If your Medicare Advantage plan denied coverage for a specialist, you can file an appeal and we can help guide you through that process. You might also consider switching plans during the next enrollment period to one that includes your preferred providers.

Answered by Ricky Gonzalez on April 8, 2025

Agent Licensed in FL, CT, LA & 8 other states

Answered by Ricky Gonzalez Medicare Insurance Agent

My Medicare Advantage plan denied coverage for a specialist I need to see. What are my options now?

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My Medicare Advantage plan denied coverage for a specialist I need to see. What are my options now?

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