What If I Don’t Agree With This Decision?

You have the right to appeal.

File your appeal in writing within 60 calendar days after the date of this notice. We can give you more time if you have a good reason for missing the deadline.

Who May File An Appeal?

You may file an appeal. If you don’t want to file an appeal yourself, you may name a relative, friend, advocate, attorney, doctor, or someone else to act as your representative. Others also already may be authorized under State law to act for you.

You can call us at: to learn how to name your representative. TTY: .

If you want someone to act for you, you and your representative must sign, date and

send us a statement naming that person to act for you.

How Do I File An Appeal?

Mail or deliver your written appeal to the address below:

We must give you a decision no later than 60 calendar days after we receive your appeal request.

What Do I Include With My Appeal?

Your written request should include: your name, address, member number, reasons for appealing, and any evidence you wish

to attach.

You may send supporting medical records, doctors’ letters, or other information that explains why we should pay for the service. Call your doctor if you need this information to help you with your appeal. You may send this information or present this information in person if you wish.

What Happens Next?

If you appeal, we will review our decision. After we review our decision, if any of the services you requested are still denied, Medicare will provide you with a new and impartial review of your case by a reviewer outside of your Medicare health plan. If you disagree with that decision, you will have further appeal rights. You will be notified of those appeal rights if this happens.

Contact Information:

If you need information or help, call us at:

Toll Free:

TTY:

Other Resources to Help You:

Medicare Rights Center:

Toll Free number 1-888-HMO-9050

Elder Care Locator

Toll Free: 1-800-677-1116

1-800-MEDICARE (1-800-633-4227)

TTY: 1-877-486-2048