In this guide 7 sections
The appeals system is slow, formal and paper-heavy, and it works far more often than families expect. A large share of first-level appeals for Original Medicare are decided in the patient’s favor, mostly because the original denial was a documentation or coding problem that the appeal fixes. The system is designed to be used. Here is how.
Before you appeal
- 1.Read the denial and identify the reason. Our guide to reading a denial letter explains how.
- 2.Call the provider’s billing office. If the denial is a coding or documentation error, a corrected resubmission is faster than an appeal and does not use up your appeal rights. Ask them to do it and confirm when it is sent.
- 3.Note the deadline. File the appeal before it, even if resubmission is in progress. You can withdraw later.
- 4.Gather: the denial notice, the MSN or plan statement, the provider’s bill, and any relevant medical records or notes.
Original Medicare: the five levels
Original Medicare (Part A and B) appeal levels
1. Redetermination
- Who decides
- The Medicare Administrative Contractor that processed the claim
- Deadline to file
- 120 days after getting the MSN; follow the notice deadline
- Decision time
- 60 days
- Notes
- Use the Redetermination Request Form or write a letter; or circle the item on the MSN, sign, and mail to the address shown. Include supporting documents.
2. Reconsideration
- Who decides
- Qualified Independent Contractor (QIC)
- Deadline to file
- 180 days from the redetermination decision
- Decision time
- 60 days
- Notes
- Independent review. Submit any new evidence here; later levels may not accept it.
3. ALJ hearing
- Who decides
- Administrative Law Judge, Office of Medicare Hearings and Appeals
- Deadline to file
- 60 days from the QIC decision
- Decision time
- 90 days (often longer in practice)
- Notes
- Requires a minimum amount in controversy, adjusted annually (around $190). Usually by phone or video. You can have a representative.
4. Council review
- Who decides
- Medicare Appeals Council
- Deadline to file
- 60 days from the ALJ decision
- Decision time
- 90 days
- Notes
- Reviews the ALJ decision for errors.
5. Federal court
- Who decides
- U.S. District Court
- Deadline to file
- 60 days from the Council decision
- Decision time
- Varies
- Notes
- Requires a higher amount in controversy (around $1,900). Rarely reached.
| Level | Who decides | Deadline to file | Decision time | Notes |
|---|---|---|---|---|
| 1. Redetermination | The Medicare Administrative Contractor that processed the claim | 120 days after getting the MSN; follow the notice deadline | 60 days | Use the Redetermination Request Form or write a letter; or circle the item on the MSN, sign, and mail to the address shown. Include supporting documents. |
| 2. Reconsideration | Qualified Independent Contractor (QIC) | 180 days from the redetermination decision | 60 days | Independent review. Submit any new evidence here; later levels may not accept it. |
| 3. ALJ hearing | Administrative Law Judge, Office of Medicare Hearings and Appeals | 60 days from the QIC decision | 90 days (often longer in practice) | Requires a minimum amount in controversy, adjusted annually (around $190). Usually by phone or video. You can have a representative. |
| 4. Council review | Medicare Appeals Council | 60 days from the ALJ decision | 90 days | Reviews the ALJ decision for errors. |
| 5. Federal court | U.S. District Court | 60 days from the Council decision | Varies | Requires a higher amount in controversy (around $1,900). Rarely reached. |
What to put in the appeal
- The patient’s name, Medicare number, and the specific item or service and date being appealed.
- A clear statement that you disagree with the decision and why, in a few sentences.
- The denial reason, quoted, and your response to it. If it says documentation was missing, include the documentation. If it says not medically necessary, include the letter below.
- A letter of medical necessity from the treating doctor. This is the most important document. It should state the diagnosis, the service, why it is necessary for this patient, what would happen without it, and how the patient meets each element of the relevant Medicare coverage rule (National or Local Coverage Determination). Generic letters lose; specific ones win.
- Relevant records: visit notes, test results, therapy notes, prior treatments tried.
- If someone other than the patient is filing, an Appointment of Representative form (CMS-1696) or documentation of legal authority.
- Copies of everything, never originals. Send by a method with tracking.
Medicare Advantage appeals
Medicare Advantage plans handle the first level themselves. You have 65 days from the initial denial notice to request a reconsideration from the plan; the plan has 30 days to decide on a service not yet received and 60 days on payment. If the plan upholds the denial, it must automatically forward the case to an Independent Review Entity, which decides within 30 days (60 for payment). After that, the ALJ, Council and court levels are the same as Original Medicare. If waiting for a standard decision could seriously harm health, request an expedited appeal, which the plan must decide within 72 hours.
Part D drug appeals
If a pharmacy cannot fill a prescription, ask for a written coverage determination from the plan; the pharmacy gives you a notice explaining how. The plan decides within 72 hours (24 hours expedited). If denied, request a redetermination within 65 days from the initial denial notice; the plan decides within 7 days (72 hours expedited). Then the Independent Review Entity, and the standard levels above. A doctor’s statement is usually required, and formulary exceptions are granted more often than families expect when the doctor explains why alternatives will not work.
Fast appeals when care is ending
Separate, faster rules apply when a hospital, skilled nursing facility, home health agency or hospice says Medicare coverage is ending. You receive a written notice and can request an immediate review by the Quality Improvement Organization (QIO), usually by noon of the day before care ends or by midnight of the discharge day for hospitals. The QIO decides within a day or two, and coverage continues during the review. This is the appeal families most often need and least often use. The notice tells you the phone number.
Free help
- SHIP: every state’s Health Insurance Assistance Program has counselors trained in Medicare appeals. 1-877-839-2675 or shiphelp.org.
- The Medicare Rights Center helpline: 1-800-333-4114.
- 1-800-MEDICARE for claim status and appeal forms.
- The Beneficiary and Family Centered Care QIO in your state for fast appeals and quality complaints.
- Legal aid organizations for complex or high-value appeals, especially at the ALJ level.
Questions families ask
What is the first step to appeal a Medicare denial?
For Original Medicare, request a redetermination from the Medicare contractor within 120 days after getting the MSN, following its instructions and deadline. Include relevant supporting documents. For Medicare Advantage, request a first-level reconsideration within 65 days from the initial denial notice.
How often are Medicare appeals successful?
First-level appeals for Original Medicare are frequently successful, especially when the original denial was a documentation or coding issue and the appeal supplies what was missing. Success rates fall at higher levels and for statutory exclusions. Medicare Advantage denials that reach independent review are also often overturned.
Can I appeal on behalf of my parent?
Yes, with authorization: a completed Appointment of Representative form (CMS-1696) signed by your parent, or documentation of legal authority such as a power of attorney. Providers can also appeal on the patient’s behalf.
What is an expedited Medicare appeal?
A fast-track appeal available from Medicare Advantage and Part D plans when a standard timeframe could seriously jeopardize health. The plan must decide within 72 hours (24 hours for Part D coverage determinations). Separately, fast appeals through the QIO apply when a hospital, facility or agency says coverage is ending.
How can a navigator help with an appeal?
By identifying whether resubmission or appeal is the right route, gathering the record, working with the doctor’s office on a letter of medical necessity that addresses the specific coverage rule, filing before the deadline, tracking each level, and connecting you with SHIP or legal aid for complex cases.
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