Medicare has a well-defined five-level appeal process. Understanding each level — its requirements, deadlines, and strategic considerations — is essential for successfully challenging Medicare denials.
Medicare's 5-Level Appeal System
Level 1: Redetermination (MAC Review)
- Filed with: Your Medicare Administrative Contractor (MAC)
- Deadline: 120 days from denial
- Decision time: 60 days
- How to file: CMS-20027 form or written request
- Success rate: Relatively low (~20%), but still worth filing
Level 2: Reconsideration (QIC Review)
- Filed with: Qualified Independent Contractor (QIC)
- Deadline: 180 days from Level 1 decision
- Decision time: 60 days
- Notable: First independent review — many cases overturned here
Level 3: Administrative Law Judge (ALJ) Hearing
- Filed with: Office of Medicare Hearings and Appeals (OMHA)
- Deadline: 60 days from Level 2 decision
- Amount in controversy: At least $180 (2024)
- Format: In-person, video, or telephone hearing
- Success rate: Often above 50%
- Key: You present your case directly to a judge
Level 4: Medicare Appeals Council
- Filed with: Departmental Appeals Board (DAB)
- Deadline: 60 days from Level 3 decision
- Decision time: 90 days (goal)
- Review: Can decline to review (Level 3 stands)
Level 5: Federal District Court
- Deadline: 60 days from Level 4 decision
- Amount in controversy: At least $1,840 (2024)
- Legal representation typically needed
Key Tips
- Always appeal Level 1 — even though success rates are lower, it preserves your rights
- Level 3 (ALJ) is the game-changer — prepare thoroughly
- Aggregate claims to meet amount-in-controversy thresholds
- SHIP (State Health Insurance Assistance Program) offers free help
- Medicare Rights Center at 1-800-333-4114 provides assistance