Our Services
Claims Support & Appeals
When a claim is denied or a bill looks wrong, you shouldn't have to fight it alone. As your local agent we help you understand the decision, gather what's needed, and file the appeal — so you get the coverage you're owed. Medicare has a formal, five-level appeals process, and a meaningful share of denials are overturned.
The appeals process
| Level | Who decides |
|---|---|
| 1. Redetermination | Your plan or the Medicare contractor |
| 2. Reconsideration | An independent review entity |
| 3. Hearing | An Administrative Law Judge |
| 4. Council review | The Medicare Appeals Council |
| 5. Judicial review | Federal district court |
Most matters resolve at level one or two. Your rights and the deadlines are set out on Medicare.gov's rights and protections pages.
Deadlines matter
Appeal windows are strict and start from the date on the notice — so the first thing to do with a denial is note the deadline, not file it away. Expedited reviews are available when waiting would jeopardise your health.
What we help with
- Reading the denial and working out the actual reason.
- Getting the supporting letter or records from your doctor.
- Filing within the deadline and tracking the response.
- Escalating to the next level if needed.
- Surprise bills, balance-billing questions, and coding errors.
Common denials worth appealing
- A drug excluded from the formulary where no alternative works — request a formulary exception.
- Prior authorization refused for a procedure your doctor considers necessary.
- Skilled nursing coverage ended earlier than expected.
- Out-of-network care in an emergency billed as if it were routine.
- Observation status rather than inpatient admission, which changes what's covered.
Free help beyond us
Your State Health Insurance Assistance Program provides free unbiased counselling on appeals, and there's no reason not to use both. We're simply the people who already know your plan.
This continues after enrolment
Claims support is why having a local agent matters more in year three than in year one. It costs you nothing — carriers pay our fee.
Not sure which of these fits you? A free 15-minute call with a licensed local advisor sorts it out — no pressure, and no cost to you. We do not offer every plan available in your area. For a complete list of every plan in your county, use Medicare Plan Compare or call 1-800-MEDICARE.
What to send us when something goes wrong
The faster we see the paperwork, the more options remain — appeal deadlines run from the date on the notice.
- The denial letter or Explanation of Benefits, including the date.
- The bill, if you've received one.
- The service date and the provider's name.
- Any letter your doctor has already written.
Don't pay a disputed bill before we've looked at it, and don't assume a denial is final — a meaningful share are overturned on the first or second level, often simply because the right documentation was never attached.
What we cannot do
We'll be straight about the limits. We're not attorneys, and we don't provide legal representation at the judicial levels of the appeals process. We can't overturn a decision that's clinically correct, and we can't promise an outcome on any individual appeal.
What we can do is make sure the appeal is filed on time, with the right evidence attached, at the right level — which is where most avoidable failures happen. Where a matter genuinely needs a lawyer or a formal advocate, we'll tell you that rather than string it out.
Questions, answered
Can you help after I've enrolled?
Yes — we stay your advisor year-round for claims, appeals, plan changes, and questions, at no cost.
How long do I have to appeal?
Deadlines are strict and run from the date on your denial notice, varying by appeal type. Note the deadline as soon as the notice arrives and call us — expedited reviews exist when waiting would harm your health.
Are appeals ever successful?
Frequently, particularly where the issue is missing documentation or a formulary exception with a doctor's support. It's usually worth pursuing.
Sources
- Medicare.gov — Your Medicare rights
- SHIP — free state health insurance counseling
- Medicare & You handbook (PDF)
- Medicare.gov — Part D costs
Figures are current-plan-year and come from the official sources above. Plan-specific costs vary by county and carrier — confirm yours on Medicare Plan Compare or with a licensed agent.
Content reviewed by Brian Penner, Independent Medicare advisor — no pressure.