Medicare Denied Claim: Out-of-Network Provider

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?

What To Do Next

1. Read your denial notice carefully. It will explain why the claim was denied and how to appeal. Note the deadline — Medicare Advantage plans give you 65 days from the date on the denial notice to file an appeal.
2. 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.
3. 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, at in-network cost-sharing, when their network is inadequate (42 CFR 422.112).
4. Ask about a continuity-of-care transition if applicable. If you were in an active course of treatment — especially if you recently joined the plan — ask your plan in writing to keep covering that treatment during the transition period.
5. 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 (42 CFR 422.592).
6. Contact 1-800-MEDICARE (1-800-633-4227) if you believe your plan is not following Medicare rules about network access.

Sources

• KFF: Medicare Advantage Prior Authorization and Denial Data, 2024 — 80.7% of appealed prior-authorization denials were overturned in 2024.
• Medicare.gov: Appeals in Medicare Health Plans — the Medicare Advantage appeal process and deadlines.
• 42 CFR 422.112: Access to Services — network-adequacy and out-of-network-at-in-network-cost-sharing rules, plus the 90-day transition for new enrollees mid-treatment (§422.112(b)(8)).
• 42 CFR 422.113: Emergency and Urgently Needed Services — plans must cover emergency and urgent care regardless of network status.
• 42 CFR 422.116: Network Adequacy — the time-and-distance standards Medicare Advantage networks must meet.
• 42 CFR 422.592: Independent Review Entity Reconsideration — upheld denials are automatically forwarded to an independent review entity.
• CMS: Medicare Advantage Network Adequacy Guidance — CMS’s operational network-adequacy guidance.
• HHS OIG: Medicare Advantage Appeal Outcomes and Audit Findings (OEI-09-16-00410) — MA plans overturned about three-quarters of their own denials on appeal (2014–2016).

Frequently Asked Questions