Medicare or Medicare Advantage (MA) Plan Adverse External Appeals 

1. Requesting an Administrative Law (ALJ) Hearing: A hearing before an ALJ gives you the opportunity to present your appeal to a new person who will independently review the facts of your appeal, provide you (and others if you wish) with an opportunity to testify, and make a new and impartial decision in accordance with the applicable law. Here are all the forms that must be completed and filed online or sent via mail. If you have an MA plan, all forms and documents must be sent by mail. 

2. Requesting a Medicare Appeals Council (MAC) Hearing: If dissatisfied with an ALJ decision or dismissal, you may request Council review. The Council may also undertake review of an ALJ decision on its own motion.  

3. What to Include in Your Appeal: 
   You should use form DAB-101 to appeal. Your appeal may also be made in writing. Your written appeal must include: 

• the beneficiary's name; 

• the beneficiary’s Medicare number; 

• the item or service in dispute; 

• the date of the item or service; 

• the date of the ALJ’s decision; and 

• your name, and, if applicable, the name of your representative; 

• a copy of the ALJ’s decision or dismissal order with your appeal. 

How to File an Appeal 

1. Your appeal must be filed, i.e., received by the Council, within 60 days after you receive the ALJ’s decision or dismissal order. The Council will assume that you received the ALJ’s action five days after the date on the decision or dismissal order, unless you show that you received it later. If you file the appeal late, you must show that you had good cause. 

2. Mail the appeal to: 

Department of Health and Human Services 
Departmental Appeals Board, MS 6127 
Medicare Appeals Council 
330 Independence Ave., S.W. 
Cohen Building, Room G-644 
Washington, D.C. 20201 

Filing in Federal District Court
If you disagree with your Medicare Appeals Council decision and the amount in controversy is at least $1,840 (2024), you may file a civil action in your local Federal District Court. The notice of decision from the Council will give you information about filing a civil action. Your request must be filed with the Federal District Court within 60 days of receiving the Medicare Appeals Council decision. 

Veteran’s Administration (VA) Plan Adverse External Appeals 

Supplemental Claim: When you choose to file a Supplemental Claim, you are adding new evidence that supports your case or identifying evidence for review. A reviewer will determine whether the new evidence changes the decision.  

• To request a review, you must fill out and send this form and all supporting documentation by mail.  

• If you would like the VA to access your medical records and information from your provider(s), you must also fill out and send this form.  

Higher-Level Review: If you disagree with a VA decision, you or your representative can request a new review of your case by a higher-level reviewer. The reviewer will determine whether an error or a difference of opinion changes the decision. You cannot submit new evidence with a Higher-Level Review. 

• To request a review, you must fill out and send this form and all supporting documentation by mail.  

• Note: higher-level reviews can take 4 to 5 months to complete.  

Board of Veterans’ Appeals: A Board Appeal may be an option for you if you submit your request within 1 year of the decision on your initial claim, Supplemental Claim, or Higher-Level Review (the 1-year time limit starts from the date on your decision letter). You can request a Board Appeal only after an initial claim, a Supplemental Claim, and a Higher-Level Review. 

• To request a Board Appeal, you can file online here or fill out a Decision Review Request Form and mailing it and any supporting documentation to:  

Board of Veterans’ Appeals 
PO Box 27063  
Washington, D.C. 20038 

• If the Board agrees to review your case, you will get a letter telling you that the Board has added your case to the docket. The docket is the list of cases for the Board to review. You do not need to do anything while you wait for a decision (or a hearing if you requested one) unless the Board sends you a letter to ask for more information.  

US Court of Appeals for Veterans Claims: Here is information about this process. If you decide to pursue this option, we highly recommend seeking support from legal counsel, which you can obtain here.  

Employer Group Health Plan (EGHP) Adverse External Appeals 

If you participate in a private-sector workplace plan that provides health benefits, the Employee Retirement Income Security Act of 1974 (ERISA) protects your health benefits and sets standards for those who administer your plan (there are exceptions for plans sponsored by government or most religious bodies).  

File a Complaint with your State Insurance Commissioner: 

1. You can find your Insurance Commissioner by clicking here and selecting your state from the drop-down box. 

2. Here is a sample letter you can use to file your complaint.  

File a Complaint with the Department of Labor (DOL) 

1. To file a health insurance complaint with the Department of Labor, you can contact the Employee Benefits Security Administration (EBSA) by calling 1-866-444-3272, filing online here, or mailing these forms to your local field office.  

2. When you file a complaint, the EBSA will review your claim to see if it appears to be a valid ERISA violation. If the complaint seems valid, the EBSA may contact your employer's health plan administrator to attempt to resolve the issue informally. If informal resolution is not possible, the EBSA may launch a formal investigation, which could include reviewing plan documents, interviewing you and other involved parties, and requesting additional information from the plan administrator. If the investigation finds a violation, the DOL may order the plan administrator to provide the benefits you were denied. In cases of egregious violations, the plan administrator may face penalties or fines. If necessary, the DOL may pursue legal action against the plan administrator to enforce compliance. 

Filing in Federal District Court: If you disagree with your ESBA decision and the amount in controversy is at least $1,840 (2024), you may file a civil action in your local Federal District Court. The notice of decision from the ESBA will give you information about filing a civil action. Your request must be filed with the Federal District Court within 60 days of receiving the ESBA decision. 

Medicaid Plan Adverse External Appeals 

File a Complaint with your State Insurance Commissioner: 

• You can find your Insurance Commissioner by clicking here and selecting your state from the drop-down box. 
• Here is a sample letter you can use to file your complaint.  

Filing an Appeal with Your State’s Medicaid Agency: You can request an appeal by writing a letter to your state's Medicaid agency. You can find your state Medicaid Agency here. You should include the notice you received, and state that you disagree with the decision. You can also request a hearing and include any witnesses you plan to bring. The state Medicaid agency will decide whether to hold an administrative fair hearing or an evidentiary hearing. At the hearing, the agency will make a written decision based on the evidence presented. The agency must take final action on the appeal within 90 days of the hearing. If the decision is favorable, the agency must implement it promptly. 

Filing in Federal District Court: If you disagree with the results and the amount in controversy is at least $1,840 (2024), you may file a civil action in your local Federal District Court. The notice of decision from the agency will give you information about filing a civil action. Your request must be filed with the Federal District Court within 60 days of receiving the decision. 

The ALS insurance Navigator™ is brought to you by Biogen and other supporters: