How Do I…?

Appeal a Denied Claim or Coverage Decision

If your plan denies a claim or refuses to cover a service, you have the right to appeal. Here's how.

1. Read the denial letter carefully. It explains why the plan said no, what service was denied, and your appeal rights. Save this letter — you'll need it.
2. Note the deadline. Appeal deadlines vary by program and plan type (typically 60 days for Medicare). The letter states yours. Act quickly.
3. Gather your records. Collect your member ID card, the denied claim notice, medical records from your doctor, prescription information, or any other proof relevant to your case.
4. File a first-level appeal. Contact your plan's appeals department (phone number is on your denial letter or ID card). You can appeal in writing, by phone, or through your online portal. State clearly why you disagree with the denial.
5. Wait for the decision. The plan has a set time to respond (often 30–60 days for routine appeals; faster for urgent cases). Track the timeline.
6. If denied again, request an independent review. Most plans must let you ask an outside reviewer to look at the case. Ask your plan how to request this (sometimes called "external review").
7. Learn your next steps. If the independent review denies you, Medicare and Medicaid members have additional appeal options. See Your Rights for details.

Choose or Change My Primary Care Provider (PCP)

Many plans require you to pick a primary care doctor (PCP) who coordinates your care. Here's how to choose or switch.

1. Check your plan's provider directory. Visit your plan's website or call member services. The directory lists all in-network doctors and their specialties.
2. Confirm the doctor is accepting new patients. Just because a doctor is in-network doesn't mean they're taking new patients. Call the office or check their online scheduling system.
3. Check hospital affiliations and office location. Make sure your doctor practices at a convenient location and works with hospitals you trust.
4. Make your selection. You can usually assign a PCP through your plan's online member portal or by calling member services. Some plans allow you to change your PCP monthly; others have annual deadlines.
5. Confirm the effective date. Ask when the change takes effect. Sometimes it's immediate; sometimes it's the first of the month after your request.

Replace a Lost Member ID Card

Your ID card has your member number and plan details. Losing it is common and easy to fix.

1. Sign in to your plan's member portal. Most plans let you download or print a temporary card instantly from their website.
2. Call member services as a backup. If you can't access the portal, call the number on your last bill or your plan's website. They can mail a replacement or give you a temporary number to use right away.
3. For a Medicare card, use Social Security's portal. Go to ssa.gov or medicare.gov to replace an Original Medicare card (red, white, blue). Medicaid cards are managed by your state.
4. Carry your member number in the meantime. Your plan will accept the number even if you don't have your physical card. Write it down or take a photo.

Read My Explanation of Benefits (EOB)

After you get care, your plan sends an EOB (not a bill). It shows what your provider billed, what the plan paid, and what you might owe. Here's how to read it.

1. Understand it's not a bill. An EOB is a summary of a claim — it explains what happened. Your provider may send you a separate bill later, or none at all if everything is covered.
2. Match the date and provider to your visit. Confirm the service date and doctor name match your records. If they don't, contact member services right away.
3. Read the "billed" amount. This is what the provider charged. This is NOT what you have to pay.
4. Check the "allowed" amount. This is what your plan negotiated to pay (usually less than the billed amount). This is the basis for your cost-sharing.
5. See what the plan paid. The EOB shows the plan's share. If the provider is in-network, this is settled — you don't owe them more.
6. Identify your responsibility. Look for "you owe" or "patient responsibility." This is your copay, coinsurance, or deductible. If it's $0, the plan covered everything.
7. Flag any errors. If the service date, provider, or amounts don't match your records, contact your plan's customer service and your provider's billing department.

Switch Plans

You can change health plans during open enrollment or certain life events. Here's how to do it smartly.

1. Identify your enrollment window. Medicare Advantage and Medicare Part D enrollees can change plans once a year (typically Oct–Dec). Medicaid and ACA Marketplace dates vary by state and situation. See Enrollment & Deadlines for your program.
2. Compare your options. Use Medicare Plan Finder (Medicare) or Healthcare.gov (ACA Marketplace). Compare premiums, deductibles, networks, and formularies (drug lists).
3. Check if your doctor is in the new plan's network. If your current doctor matters to you, confirm they're in-network at the new plan before you enroll.
4. Enroll in the new plan during open enrollment. You can enroll online, by phone, or through an agent or broker. Your old plan ends automatically (for Medicare Advantage and Part D, usually Dec. 31); you don't have to cancel it.
5. Confirm coverage begins on the new plan's effective date. Usually Jan. 1 for Medicare changes, but check your enrollment confirmation.
6. Don't drop existing coverage early. Wait until your new plan is active to cancel or drop the old one. Gaps in coverage can be expensive.

Arrange Non-Emergency Medical Transportation (NEMT)

If you can't drive to medical appointments, some Medicaid and Medicare Advantage plans offer free or low-cost transportation.

1. Check if your plan covers NEMT. Look at your plan documents or call member services. NEMT is common in Medicaid but not all Medicare plans offer it. Ask what types of trips are covered (appointments, dialysis, etc.).
2. Call ahead with required notice. Most plans need you to schedule 24–48 hours in advance. The number is on your ID card or in your plan materials.
3. Confirm the appointment and trip details. Give the driver or dispatcher the date, time, location of your appointment, and your pickup address. Confirm the pickup time.
4. Verify eligibility of the trip. Not all trips are covered. Confirm the appointment destination is an eligible provider and the trip reason qualifies (e.g., to a doctor's office, hospital, or dialysis center).
5. Arrange backup transportation. If NEMT isn't available or the trip isn't covered, ask member services about other options: rideshare vouchers, taxi discounts, or paratransit programs in your area.

Get Help Understanding My Options

Health coverage is complex. Free, unbiased advisors can help you understand your rights and options.

1. Contact your SHIP (State Health Insurance Assistance Program). SHIPs are free, unbiased counseling services funded by Medicare. Call shiphelp.org to find your state's number. They help with Medicare questions, appeals, and enrollment.
2. Call your State Medicaid agency. Visit our State Directory to find your state's Medicaid contact. They can explain your eligibility, benefits, and how to renew coverage.
3. Reach 1-800-MEDICARE for Medicare questions. Call 1-800-633-4227 (1-800-MEDICARE). It's free, available 24/7, and multilingual. Have your ID card handy.
4. Ask your health plan's member services. Your plan's customer-service team can walk you through benefits, costs, and how to use your coverage.
5. Use a broker or navigator if you're enrolling. Brokers and patient advocates can help you choose a plan. Some services are free; ask about fees upfront. For Medicare, look for counselors at CMS.gov.

Common Questions