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 June 16, 2025

Agent Licensed in WA

Answered by Esther Miller Medicare Insurance Agent

James Romeo · Answer

We always advise to Contact the Insurance Company and see why it was denied. Most of the time they just need more information as to why the doctor or you are doing or wanting done and why. Just needing more information. You also need to check the network IF you have a HMO and that doctor is not in the network then you may be out of luck. But If you have a PPO there could be Out Of Network Benefits. just a higher cost. Usually for whatever specialist there should be that specially options in network. The last step with the insurance company is to Appeal there decision and they can make a determine if they overturn the appeal. And the very last step after getting all of the information and if they deny the appeal then you can file a Grievience and Formal Complaint with Medicare and they will launch h and investigation but only do that after trying to work with your Insurance Company. So fist call to the Insurance Company and your Doctor office that will get out the rest of the story and then go from there.

Answered by James Romeo on June 12, 2025

Broker Licensed in MN

Answered by James Romeo Medicare Insurance Agent

Bob Greco · Answer

Your options would depend on the type of program you have. Do you have an HMO or a PPO? If you have an HMO you’re limited to the network that is provided by the program. If you have a PPO, you can go outside the network as long as the provider agrees to except your coverage. You can always go back to your primary care physician for another recommendation. You may also have the option to go to another program if there is a special enrollment available for you.

Answered by Bob Greco on June 16, 2025

Agent Licensed in MO, IA & IL

Answered by Bob Greco 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

Carol Thompson · Answer

You can have an agent assist in seeking if your specialist is in the network; if they are not then An agent can recommend another specialist to you that is in the network. 

The specialist can submit a request to your plan requesting that your care is medically necessary to see if the carrier will accept.

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

Larry Pereiro · Answer

You have two options, find a specialist in network in you are in an HMO or see that specialist if you are in a PPO with the knowledge that you will pay higher out of pocket cost for the service.

Chuck Winslow · Answer

You need to connect with you agent and if you do not have one, you can call me and I will help you with the paperwork. 

463-204-8050

Fran Lovelace · Answer

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

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.

Toni Johnson · Answer

Your specialist may be Out-of-Network for the type of you plan you have. You may still see the specialist and pay full price or find a specialist that is in-network of providers for your selected plan.

Answered by Toni Johnson on May 19, 2025

Agent Licensed in FL, IN, MO & 5 other states

Answered by Toni Johnson Medicare Insurance Agent

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

Lyle Affleck · Answer

The majority of Medicare Advantage Plans will force you to stay within their network. Remember, though, that your part B will (after your initial Part B deductible) will pay for 80% of the visit as long as the doctor accepts Medicare. You can still see the doctor though they may be "out of network" knowing you will have more than the usual amount out of pocket.

Answered by Lyle Affleck on June 23, 2025

Agent Licensed in UT, CO, FL & 8 other states

Answered by Lyle Affleck 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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