Medicare Advantage Out-of-Network Denied: Appeal

One of the biggest differences between Original Medicare and Medicare Advantage is network restrictions. Original Medicare allows you to see any Medicare-enrolled provider in the country. Medicare Advantage plans — particularly HMO plans — restrict you to a network of contracted providers. When you receive care outside that network, a denial is common. But that denial is not always the final word.

HMO vs. PPO: How Network Rules Differ

Medicare Advantage HMO Plans HMO (Health Maintenance Organization) plans have strict network requirements. Except in emergencies, you must receive care from in-network providers. If you see an out-of-network provider, the plan will typically deny the claim entirely — you may be responsible for the full cost.

Medicare Advantage PPO Plans PPO (Preferred Provider Organization) plans offer more flexibility. You can see out-of-network providers, but you pay higher cost-sharing. The plan covers a portion of the cost even for out-of-network care, although at a lower benefit level than in-network.

Understanding which type of plan you have is the first step in determining your rights.

The Emergency Exception: Always Applies

Federal law requires Medicare Advantage plans to cover emergency care from any provider, regardless of network status, at the in-network cost-sharing level. An emergency is defined as a situation where a reasonable person would believe that waiting to get care from an in-network provider would result in serious harm.

If your claim was denied because you received emergency care from an out-of-network provider, that denial may be improper. The plan must cover the emergency care at the in-network rate. This rule applies everywhere — including outside your plan's service area, including when traveling.

Post-stabilization care: After emergency stabilization, plans have the right to arrange transfer to an in-network facility. However, if the plan fails to arrange transfer in a timely manner, continued out-of-network care must be covered.

Continuity of Care After Plan Change

If you changed Medicare Advantage plans (for example, during annual open enrollment) and your previous provider is not in your new plan's network, you have a right to continuity of care for ongoing treatment. CMS rules require new MA plans to:

• Allow you to continue seeing a current treating provider who is not in-network for an initial period (typically 90 days) for active treatment
• Honor Prior Authorization Denied: How to Appeal" class="auto-link">prior authorizations from the previous plan during the transition period

If your new plan denied a claim for ongoing treatment from a provider who was previously in-network under your old plan, invoke your continuity of care rights in the appeal.

Network Adequacy: When You Can't Find an In-Network Provider

CMS requires Medicare Advantage plans to maintain adequate networks of providers across all specialties. Network adequacy standards specify maximum travel times and distances to specialists, hospitals, and other providers.

If in-network providers in the specialty you need are unavailable — long wait times, not accepting new patients, geographic inaccessibility — the plan may be required to approve out-of-network care at in-network cost-sharing rates. Document your attempts to find in-network care:

• Call logs showing in-network specialists are not accepting new patients
• Evidence of wait times exceeding CMS standards
• Geographic distance calculations if the nearest in-network provider is unreasonably far

How to File a CMS Network Adequacy Complaint

If you believe your plan's network is inadequate, file a complaint with CMS. CMS monitors MA plan networks and has authority to require plans to expand their networks or approve out-of-network care when the network fails.

File at medicare.gov/talk-to-someone or call 1-800-MEDICARE. You can also contact your state insurance department, which may have concurrent authority over MA plans.

The 5-Level Appeal Process

Level 1 — Redetermination by the Plan: File within 60 days of the denial. Attach documentation of the emergency, continuity of care situation, or network inadequacy.

Level 2 — IRE Reconsideration: File within 60 days of the plan's redetermination. The IRE applies CMS coverage criteria independently.

Level 3 — ALJ Hearing at OMHA: File within 60 days if the amount in controversy meets the threshold.

Level 4 — Medicare Appeals Council: File within 60 days of ALJ decision.

Level 5 — Federal District Court: Available after exhausting administrative options.

What to Include in Your Appeal

• Documentation establishing why out-of-network care was necessary
• For emergencies: emergency department records and documentation that the situation met the emergency standard
• For continuity of care: prior authorization records from your previous plan, treatment records
• For network inadequacy: call logs, provider directory screenshots, evidence that in-network providers were unavailable
• A physician letter explaining why in-network alternatives were not feasible

SHIP Counselors for Network Disputes

SHIP counselors (shiphelp.org) have experience with Medicare Advantage network denial appeals and can help you identify the strongest arguments for your specific situation. Contact them before your appeal deadline.

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Related Reading:

• How to Write an Insurance Appeal Letter
• What Is Medical Necessity?
• Internal vs External Insurance Appeal