🎯 Purpose
To help Medicare Advantage clients understand and respond to a denial of a prior authorization or claim in a professional, supportive, and effective manner — ensuring they know their rights, appeal options, and next steps.
✅ Common Reasons for Denial
Not Covered by the Plan
The service, item, or drug is not included in the benefits outlined by their specific Medicare Advantage plan.
Administrative or Documentation Error
The provider may have submitted the request with incorrect codes, missing clinical notes, or incomplete documentation.
Step Therapy or Alternative Required
The plan wants the client to try a different (often lower-cost) treatment or medication before approving the requested service.
Deemed Not Medically Necessary
The plan does not believe the requested service is reasonable and necessary based on current medical guidelines or plan criteria.
👣 Step-by-Step Process
Step 1: Listen and Acknowledge
Let the client explain what happened and how they found out about the denial. Acknowledge their frustration and reassure them that you can help them navigate the next steps.
Step 2: Gather Key Information
Collect the following:
- A copy of the denial letter or Explanation of Benefits (EOB)
- The date of service or request
- The name of the provider involved
- Details about the service, procedure, or medication in question
Ask the client:
- Did their doctor or provider already try to appeal?
- Has anything been submitted since the denial?
Step 3: Identify the Reason for Denial
Use the denial letter or call the plan with the client to determine:
- Which of the 4 reasons applies
- If the denial is for a prior authorization (before service) or a claim denial (after service)
Record the plan’s stated reason for denial and any reference number from the call.
Step 4: Coordinate with the Provider’s Office
Contact the provider’s billing or prior authorization department.
- Ask if they plan to resubmit or appeal.
- Ensure they understand why the denial happened.
- Ask if they can provide supporting documentation or a letter of medical necessity.
Step 5: Help the Client File an Appeal (if needed)
If the provider won’t file an appeal, or if the client wants to submit one personally:
- Request the Appeal Form from the plan or download it from the plan’s website.
- Help the client draft a simple letter explaining:
• Why they believe the denial was incorrect
• Any supporting facts or doctor statements
• Request a reconsideration
- Attach supporting documentation (letters, notes, EOBs)
- Submit via fax or certified mail and note the date
Step 6: Follow Up
- Track the submission and note any deadlines (usually 30–60 days to appeal).
- Set a reminder to follow up in 7–10 days.
- Keep the client updated as new information becomes available.
Step 7: Explore Alternatives if Denial is Upheld
- Ask the provider if they can recommend an alternative treatment or medication.
- Check if there’s a formulary exception, tier exception, or single-case agreement that can be requested.
- If no solution is found, help the client:
• File a Level 2 appeal (Independent Review)
• Consider a Medicare Advantage Disenrollment if appropriate during an eligible enrollment period
🧾 Documentation Checklist (For Your CRM/Client File)
- ❏ Client name and contact info
- ❏ Date denial was reported
- ❏ Summary of service denied and reason
- ❏ Copy of denial letter or EOB
- ❏ Notes from provider contact
- ❏ Appeal form and submission date
- ❏ Follow-up dates and outcomes