Medicare Insurance Appeals: Complete Guide for Seniors

Medicare has its own multi-level appeals process that differs from private insurance. Whether you have Original Medicare, a Medicare Advantage plan, or Part D drug coverage, this guide walks you through every step.

Medicare's 5 Levels of Appeal

Level 1: Redetermination

  • File with the Medicare Administrative Contractor (MAC)
  • Deadline: 120 days from the date on the Medicare Summary Notice
  • Decision within 60 days

Level 2: Reconsideration

  • Filed with a Qualified Independent Contractor (QIC)
  • Deadline: 180 days from Level 1 decision
  • Decision within 60 days

Level 3: Administrative Law Judge (ALJ) Hearing

  • Minimum amount in controversy required (updated annually)
  • Deadline: 60 days from Level 2 decision
  • Decision within 90 days

Level 4: Medicare Appeals Council

  • Deadline: 60 days from ALJ decision
  • Decision within 90 days

Level 5: Federal District Court

  • Minimum amount in controversy required
  • Deadline: 60 days from Council decision

Medicare Advantage Plan Appeals

  • First level: Appeal to the plan directly
  • If denied: Automatic review by an independent organization
  • Same higher-level appeals (ALJ, Council, Court) apply

Part D Drug Coverage Appeals

  1. Coverage determination from the plan
  2. Redetermination by the plan
  3. Independent Review Entity (IRE)
  4. ALJ hearing
  5. Medicare Appeals Council / Federal Court

Tips for Success

  • Always meet deadlines — they are strictly enforced
  • Contact your State Health Insurance Assistance Program (SHIP) for free help
  • Request expedited review for urgent situations (72 hours)
  • Include a physician's supporting statement with every appeal

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Frequently Asked Questions

What is SHIP and how can they help?

SHIP (State Health Insurance Assistance Program) provides free, unbiased counseling to Medicare beneficiaries. They can help you understand denials, file appeals, and navigate the Medicare system. Find your local SHIP at shiphelp.org.

Can Medicare Advantage deny something Original Medicare covers?

Medicare Advantage plans must cover everything Original Medicare covers. They can add extra benefits but cannot provide less coverage. If your MA plan denies something covered by Original Medicare, you have strong grounds for appeal.

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