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Medicare Denied Claim: Out-of-Network Provider

Name: Medicare Denied Claim: Out-of-Network Provider
Creator: Barley Billing Team
Published: 2026-03-26

Written by Barley Billing Team, Medicare Billing Experts | Last reviewed March 26, 2026

Does your notice say something like this?

"Services not provided or authorized by designated network providers"

"This provider is not in your plan's network"

"Out-of-network provider — not covered"

If so, you're in the right place. Here's what it means and what to do.

What This Means

Your Medicare Advantage plan denied your claim because the doctor, hospital, or other provider who treated you is not part of your plan’s approved network. The plan is saying it will not pay for care from this provider.

This type of denial is almost always a Medicare Advantage issue. Original Medicare does not use provider networks — if you have Original Medicare (Parts A and B without a Medicare Advantage plan), you can see any provider who accepts Medicare.

Why This Happens

You saw a specialist or provider outside your plan’s network. Most Medicare Advantage HMO plans only cover care from in-network providers, except in emergencies.
Your provider recently left the network. Providers can leave a plan’s network at any time. If your provider left after you scheduled your appointment, you may not have known.
The plan’s provider directory was inaccurate. Studies have found that Medicare Advantage provider directories frequently contain errors, listing providers who are no longer in-network.
You received care while traveling. Some plans have limited coverage outside their service area for non-emergency care.

Should You Appeal?

Appeal outlook: Mixed — but worth pursuing in many cases

Research from the HHS Office of Inspector General has found that about 75% of Medicare Advantage denials that are appealed are overturned. Your chances are stronger if any of the following apply:

There was no in-network provider available. Medicare Advantage plans are required to maintain adequate networks. If no in-network provider could offer the service you needed within a reasonable distance or wait time, your plan must cover out-of-network care at in-network cost-sharing rates.
You were in the middle of treatment. CMS rules require plans to honor continuity of care for at least 90 days when a provider leaves the network or when you switch plans.
It was an emergency. Medicare Advantage plans must cover emergency care regardless of network status.
The provider directory was wrong. If you relied on your plan’s directory and it listed the provider as in-network, that supports your appeal.

Your appeal is less likely to succeed if you knowingly chose an out-of-network provider and your plan had available in-network alternatives.

What To Do Next

Read your denial notice carefully. It will explain why the claim was denied and how to appeal. Note the deadline — most Medicare Advantage plans give you at least 60 days to file an appeal.
Check your plan’s provider directory. If the provider was listed as in-network at the time of your visit, save a screenshot or printout as evidence for your appeal.
Ask your plan about network adequacy. If no in-network provider was available for the service you needed, request that your plan cover the out-of-network care. CMS requires plans to arrange out-of-network coverage when their network is inadequate.
Request a continuity of care exception if applicable. If you were mid-treatment when the provider left the network, ask your plan for this exception in writing.
File your appeal. Include a letter explaining why you believe the care should be covered, along with any supporting documents. If your plan denies your appeal, the case is automatically sent to an Independent Review Entity for a second review.
Contact 1-800-MEDICARE (1-800-633-4227) if you believe your plan is not following Medicare rules about network access.

Sources

Want us to review your denial for free? Send us your notice and we'll tell you if it's worth appealing →

Appeal Deadlines — Check Your Notice for Exact Dates

Original Medicare

120 days from the date on your MSN

Medicare Advantage

At least 60 days (check your denial notice for exact deadline)

Not sure which you have? Check the top of your denial notice. If it names a private insurance company (like Humana, UnitedHealthcare, or Aetna), you have Medicare Advantage. If it says "Centers for Medicare & Medicaid Services," you have Original Medicare.

Frequently Asked Questions

Does Original Medicare have networks?

No. Original Medicare (Parts A and B) does not use provider networks. You can see any doctor or hospital that accepts Medicare. Out-of-network denials almost always involve Medicare Advantage plans.

What if I didn't know the provider was out of network?

If your plan's provider directory listed the provider as in-network, or if you were referred to the provider by an in-network doctor, you may have grounds for an appeal. Save any evidence that you relied on your plan's information.

Can my plan cover out-of-network care in an emergency?

Yes. Medicare Advantage plans must cover emergency and urgently needed care at any hospital or facility, regardless of network status. If your emergency care was denied as out of network, you should appeal.

What is a continuity of care exception?

If you were in the middle of treatment when your provider left the network (or when you switched plans), CMS rules require your plan to cover ongoing treatment with that provider for at least 90 days. This is called a continuity of care exception.

Want Us to Check Your Denial?

Send us your denial notice and we'll review it for free. We'll tell you if it's worth appealing and exactly how to do it.

This information is for educational purposes only and is not legal or medical advice. Always verify with your doctor's office and insurance company.