How to Appeal Your Medicare or Advantage Plan Denial

If you’re denied Medicare coverage or payment for a hospital stay, doctor's visit, or medical procedure, here's how to appeal.

By , Attorney · Loyola Law School

When Medicare denies a claim for health care items or services, you have the right to appeal if you disagree with the decision, whether your claim is filed under:

Appealing a decision under Medicare Part C is a little different than appealing decisions under Parts A and B, so you'll need to follow the correct appeals procedure for the Medicare benefit you're contesting.

Medicare Appeal Basics

There are up to five potential levels of standard appeals that Medicare beneficiaries (or health care providers) can pursue if a Part A, B, or C claim is denied.

Regardless of which coverage is in question, the first three levels of the appeals process are surprisingly "user-friendly." But you'll need to be sure you understand and follow the instructions at each level of appeal—particularly the deadlines for filing your appeal.

You might also encounter a minimum claim amount, also called the "amount in controversy" (AIC)—especially in later rounds of appeals. The amount in controversy is the minimum amount your claim can be worth for you to be eligible to appeal it.

Your Medicare or Advantage Plan Determination Notice

Medicare hires private contractors to process Part A and Part B claims. Part C claims are processed by the private insurer handling your managed care plan. But whether you're requesting Part A, B, or C benefits, the claims processor must send you a written notice telling you whether your claim (or request for prior authorization) has been approved or denied.

For Medicare Parts A and B, this notice is called a Medicare Summary Notice (MSN). For Part C, it's called an Organization Determination. Either way, the notice will state whether Medicare or your managed care insurer is allowing or denying coverage or reimbursement for the specific medical items or services that you or your health care provider requested.

If your claim or preauthorization is denied, the determination notice will explain the denial. For example, it might say the denied service or item wasn't "medically reasonable or necessary." The notice will also tell you how to request an appeal.

How the Medicare Appeals Process Works

There are five levels of appeals for Medicare Parts A and B and Advantage Plans (Part C). The process is the same for Part A and Part B claims. But the appeals process for a Medicare Advantage Plan or Part C denial differs somewhat in the first two stages because, with Medicare Advantage, you're dealing with a private insurer and not a claims processor contracted by Medicare.

Level 1 Medicare Appeals

The first level of a Medicare Part A or B appeal is called a Request for Redetermination. With Part C, it's called a Request for Reconsideration.

Both types of level one appeals are "paper reviews" of your claim. That means the review is based on your medical records, and you won't need to appear in person. And you can appeal any claim amount—meaning there's no minimum "amount in controversy" (AIC) required for this first level of appeal.

Medicare Parts A and B: You'll have 120 days after receiving your Medicare Summary Notice to file a written "Request for Redetermination." The directions and deadlines are detailed in your MSN decision letter.

The same Medicare contractor that processed your initial Medicare claim will make a new and independent review of your claim file and issue a new decision. But your claim will be reviewed by a different person than the one who originally processed your claim.

Medicare Advantage (Part C): You'll have only 60 days after receiving your Organizational Determination letter to file a "Request for Reconsideration." Again, you'll need to follow the directions in your determination letter to file an appeal.

Generally, you'll receive a Part C reconsideration decision within:

  • 72 hours for expedited requests (submitted by your doctor)
  • 30 days for standard requests involving prior authorization for medical services, or
  • 60 days if the decision involves a request for payment (including reimbursements).

Level 2 Medicare Appeals

Level 2 appeals for Medicare Parts A, B, and C all involve having an Independent Review Entity hired by Medicare to conduct a new, on-the-record review of your claim—meaning it's again based on your medical records with no need for you to appear. And there's no minimum amount in controversy (AIC) required for a Level 2 appeal.

But with a level 2 appeal, you can send any material you want the independent reviewer to consider in your appeal.

Medicare Parts A and B: To appeal the Level 1 decision on your Part A or B claim, you must file a written Request for Reconsideration by a Qualified Independent Contractor (QIC) within 180 days of receiving the Level 1 Redetermination Decision. Your Level 1 Redetermination Decision will tell you where to send your appeal request.

Medicare Part C: You don't have to request a level 2 appeal for Part C claims. Your claim will automatically be forwarded to an outside Independent Review Entity (IRE), sometimes called a "Part C QIC," if your Medicare Advantage Plan:

  • doesn't find in your favor during the level 1 review, or
  • fails to issue a decision on your Level 1 appeal within the response deadlines noted above.

The IRE will send you a decision letter that includes information about your right to appeal to the next level.

Level 3 Medicare Appeals: Administrative Law Judge Hearing

Whether you're appealing a Part A, B, or C claim, you'll have 60 days after receiving your Level 2 decision to file a Level 3 appeal: a Request for Hearing with the Office of Medicare Hearings & Appeals.

All level 3 hearings are held before an administrative law judge (ALJ). The Office of Medicare Hearings & Appeals (OMHA) and its ALJs are independent of Medicare and are part of the U.S. Department of Health & Human Services (HHS).

To file a Level 3 appeal, you'll need to meet the minimum "amount in controversy" (AIC requirement), which changes annually. Your Level 2 Decision notice will indicate the minimum AIC you need. In 2024, the minimum AIC to request a hearing is:

  • $180 for a dismissal, and
  • $200 for reconsiderations issued by a Quality Improvement Organization.

You might consider getting legal advice before requesting an ALJ hearing, but it's not required. The hearings are informal proceedings, and you're not expected to know the rules of evidence to present your case.

But having an attorney represent you can increase your chances of winning the appeal. You can also appoint a personal representative to appear on your behalf, such as a:

  • spouse
  • friend
  • caregiver, or
  • patient advocate.

If you change your contact information, such as your telephone number or address, immediately notify the ALJ assigned to your case. If you have any questions or concerns about the hearing process, contact your OMHA field office for assistance.

(See below for more on what happens at a Medicare appeal hearing.)

Level 4 Appeals: Medicare Appeals Council Review

If you receive an unfavorable Level 3 ALJ decision (like a denial) for your Part A, B, or C Medicare Appeal (or the ALJ dismisses your case), you'll have 60 days to file a written Request for Review with the Medicare Appeals Council (MAC).

The MAC review is conducted on the record and is independent of the OMHA and Level 3 ALJ reviews. Before requesting a Medicare Appeals Council Review, you should consider talking to a lawyer.

Level 5 Appeal: Federal District Court Civil Lawsuit

If you disagree with the MAC's Level 4 decision and the amount in controversy (AIC) is at least $1,840 (in 2024), you can file a civil action in your local federal district court. The MAC's Notice of Decision will give you information about filing a civil action—the last level of appeal available to you.

Your lawsuit must be filed within 60 days of receiving the unfavorable MAC Decision. And as this is a formal court proceeding, you'll need to hire a Medicare or Social Security lawyer before filing a lawsuit.

What to Expect at a Medicare Appeal Hearing

The ALJ hearing (the level 3 appeal) at the Office of Medicare Hearings & Appeals is your first opportunity to speak directly to someone who can approve your claim. It's your chance to present your case and any witnesses you want to testify on your behalf.

The ALJ might ask other witnesses—including physicians or other experts—to attend your hearing. You'll be able to question those witnesses.

Where Are ALJ Hearings Held?

You should receive a Notice of Hearing at least 20 days before the hearing date. You must fill out and return a "Response to Notice of Hearing Form" to the ALJ listed on the Notice of Hearing within the time limit set forth on the notice.

The notice you receive will tell you where and when your Medicare ALJ hearing will take place. Hearings are held in one of three ways:

  • by telephone
  • by video teleconference (VTC), or
  • in-person at one of the four OMHA field offices (at the discretion of the ALJ).

In-person hearings. You must request an in-person hearing in writing and submit an explanation as to why the hearing needs to be in-person. The ALJ will grant your request if "good cause" exists for you to appear in person rather than by VTC or telephone. Even if you don't request an in-person hearing, the ALJ could decide that the circumstances in your case warrant an in-person hearing.

Video conferences. It's very common for the ALJ to set up a VTC from a location near your home. You'll be asked to go to the VTC location, which has private rooms with video cameras and televisions that allow you and the ALJ (who's at the field office location) to see and talk to each other.

An on-site technician sets up the equipment, but the technician isn't otherwise present during the hearing and can't hear your conversation with the ALJ. Your representative or someone else you want to accompany you and your witnesses can attend at the VTC location. The OMHA field office staff will work with you to find a convenient VTC location near your home.

Telephone hearings. In some cases, a telephone hearing might be used for the convenience of the parties attending the hearing.

On-the-record decisions. In other cases, you might be notified that you won't need to have a hearing. If the evidence in your case file strongly supports a decision in your favor, the ALJ can choose to skip the hearing and decide your case "on the record."

If you can't attend your hearing. Contact the ALJ immediately if you can't attend the scheduled hearing or if you object to the time or place set for your hearing. If you have good cause for changing the time or place of the hearing, it will be rescheduled. If you fail to appear at your hearing without a good reason, the ALJ can dismiss your case.

What Happens at the OMHA Hearing

At the start of the hearing, the ALJ will introduce everyone in attendance. That could include any of the following:

  • field office staff assisting in the hearing process
  • witnesses, doctors, or other experts the ALJ has asked to attend, and
  • anyone else the ALJ deems necessary and proper to attend the hearing.

You and all the witnesses who intend to testify will be placed under oath—both your witnesses and those invited by the ALJ.

The judge will explain the issues in your case and will question you and the witnesses. You or your lawyer can also question any witnesses appearing at your hearing. All hearings are audio-recorded.

The ALJ will make an impartial review of the facts and determine the credibility of all the evidence, including the following:

  • testimony from your hearing
  • documents contained in your claim file, and
  • the applicable rules in reaching a decision.

Fast Appeals for Medicare Part A

If a hospital or nursing facility tries to discharge you earlier than you think you should be discharged, you can file an expedited appeal. See our articles on appealing a hospital discharge and appealing a discharge order from a nursing or rehab facility.

Where to Get Additional Information

For more information on the Medicare appeals process, go to the:

If you need help filing your appeal, you can contact:

For a comprehensive reference book that discusses Medicare appeal hearings, see Nolo's book Social Security, Medicare, and Government Pensions, by attorney Joseph Matthews.

Updated December 11, 2023

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