How to Appeal Your Medicare or Advantage Plan Denial

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:

• Medicare Part A (hospital coverage)
• Medicare Part B (doctor's office coverage), or
• Medicare Part C (a Medicare Advantage Plan).

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 may 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 are 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 Avantage, 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.

Most hearings are held by telephone or videoconference (VTC) from a remote hearing site. But you might have an in-person hearing at an OMHA field office if you can show "good cause" for you to appear in person. If the evidence in your claim file supports a decision in your favor, the ALJ might decide to forgo a hearing altogether and decide the case "on the record."

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.

You can also present witnesses 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 any witness who testifies at your hearing. All hearings are audio-recorded.

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.

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 Medicare.gov appeals page
• the Office of Medicare Hearings & Appeals website, or
• the Departmental Appeals Board website.

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

• your State Health Insurance Assistance Program (SHIP)
• the California Health Advocates (HICAP), or
• the Center for Medicare Advocacy.

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

_{Updated November 20, 2023}