My Medicare Advantage plan denied coverage for a specialist I need to see. What are my options now?
Answered by 5 licensed agents
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.
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.
Answered by Michael Pyers on April 7, 2025
Broker Licensed in OH & MI
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.
Answered by Steve Brauer on April 8, 2025
Broker Licensed in AZ & CA
Find another one. You’ll have to get a new referral from your Dr. or ask Medicare Call 1-800- Medicare for assistance
Answered by Mike Henry on April 20, 2025
Agent Licensed in TX
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
Tags:
Advice for Seniors
Coverage
Medicare Advantage
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