Where to turn when a letter isn't enough

The plan didn't answer by its own deadline

The plan's own deadline to decide passed with no decision recorded. Under Medicare's rules, that silence is legally treated as if the plan denied the appeal again — and the plan is required to forward your case to an outside reviewer automatically, without you having to ask.

1. Call the plan and ask for the case number it used to forward your appeal to the Independent Review Entity (C2C Innovative Solutions).
2. If the plan says it hasn't forwarded the case, tell them it was required to under 42 CFR § 422.590 once its own deadline passed.
3. If the plan still won't act, file a grievance with the plan — a grievance is a complaint about the plan's conduct, separate from the appeal itself.
4. File a complaint with 1-800-MEDICARE so there's a federal record of the delay.

The plan or C2C should confirm a case number for the forwarded appeal. A grievance gets its own written response from the plan, separate from your appeal.

The Independent Review Entity is overdue

The Independent Review Entity (C2C Innovative Solutions) has passed its own deadline to decide your case with no decision recorded.

1. Call C2C and ask for the status of your case using your case number.
2. If C2C can't explain the delay, file a complaint with 1-800-MEDICARE.

C2C should be able to tell you the status of your case and an expected decision date.

Your case is below the dollar amount required for the next level

Appealing to an Administrative Law Judge requires a minimum dollar amount still in dispute. Your case's amount doesn't currently meet that threshold, so this specific appeal can't go further on its own.

1. Ask a SHIP counselor for a free second opinion on your options.
2. If you have other denied claims from the same or a related situation that share the same basic facts, ask whether they can be combined (aggregated) to reach the threshold.
3. If a new, separate denial arrives later, you can start a new reconsideration for it.

Aggregating claims to meet the threshold has its own rules about what counts as related claims — a SHIP counselor or advocate can help you work through whether yours qualify.

This is where a human often helps

Your case has reached the Administrative Law Judge level or higher. Hearings at this level are more formal, and many families bring in help at this point.

1. An elder-law attorney (find one through NAELA's directory) can represent you at the hearing.
2. A board-certified patient advocate (Umbra Health Advocacy or Greater National Advocates list independent advocates) can help prepare your case — advocates commonly charge flat fees, often in the few-hundred-dollar range for earlier levels and higher for an ALJ hearing.
3. The Center for Medicare Advocacy's free self-help packets are a starting point even if you don't hire anyone.
4. You'll need to file OMHA-100 to request the hearing.

The ALJ hearing is usually held by phone or video, not in person. You, your representative, or both can take part.

You're past the deadline to file

The deadline to file this appeal has passed. You may still be able to file if you have good cause for the delay.

1. You can still ask the plan to accept your appeal for good cause — for example, a serious illness, a family emergency, or not having received the notice.
2. The plan decides whether your reason counts as good cause; there's no guaranteed list, so explain your specific situation.
3. A SHIP counselor can help you write the good-cause request.

The plan reviews good-cause requests case by case — being specific and honest about what happened is what matters, not using particular words.

The facility sent this bill to collections

You told us the facility sent this bill to collections while the Medicare appeal is still open.

1. Tell the facility or collector, in writing, that the charges are currently under a Medicare appeal and ask them to pause collection until it's resolved.
2. Keep a copy of whatever you send and any response.
3. You have rights around how a debt collector can contact you — the CFPB's page explains them in plain language.

If the appeal is later decided in your favor and the plan pays, the bill is void — keep your appeal paperwork in case you need to show that later.

You missed the fast-appeal deadline

The deadline to ask for an immediate fast-track review passed. A standard appeal is still available if you're within its own deadline.

1. A standard reconsideration is still available within 65 days of the notice, even though the fast-track window closed.
2. If the facility later bills you for the days in question, that bill itself can be appealed.

A standard appeal takes longer than the fast-track review would have, but it's a real option.

You mentioned she also has Medicaid

When someone has both Medicare and Medicaid, Medicaid may cover something the Medicare Advantage plan denied.

1. Ask your state's Medicaid managed-care ombudsman (shown below if we have one for your state) whether Medicaid covers what was denied.
2. If your plan is a Dual Eligible Special Needs Plan (D-SNP), some appeals for Medicare and Medicaid services are handled together — ask the plan directly how that works for your specific denial.

Medicaid rules and contacts vary a lot by state — a state-specific line is the fastest way to get a real answer.

I have a concern about the quality of care, not a coverage decision

A quality-of-care concern (something felt unsafe, was done wrong, or harmed someone) is handled differently from a coverage appeal — by the same Beneficiary and Family-Centered Care Quality Improvement Organization (BFCC-QIO) that handles fast appeals.

1. Call your state's BFCC-QIO (shown below) and say you want to file a quality-of-care complaint, not an appeal.
2. You can also file this kind of complaint anonymously if you prefer.

The QIO reviews quality complaints separately from any coverage appeal you may also have going.

I have a complaint about how the plan treated us, not about a coverage decision

A complaint about the plan's own conduct — rudeness, long hold times, being given wrong information — is a grievance, which is different from appealing a coverage decision.

1. File a grievance directly with the plan — every plan has a grievance process it must follow.
2. You can also file a complaint with 1-800-MEDICARE.

The plan must respond to a grievance within its own required timeframe, separate from any appeal.