How to Appeal a Medicare Denial

Medicare has a structured 5-level appeal process that provides strong protections. Whether you have Original Medicare or a Medicare Advantage plan, you have the right to challenge any denial.

Medicare's 5-Level Appeal Process

Level 1: Redetermination

  • Who reviews: Your Medicare contractor (MAC)
  • Deadline to file: 120 days from denial
  • Decision time: 60 days

Level 2: Reconsideration

  • Who reviews: Qualified Independent Contractor (QIC)
  • Deadline to file: 180 days from Level 1 decision
  • Decision time: 60 days

Level 3: Administrative Law Judge (ALJ) Hearing

  • Who reviews: Office of Medicare Hearings and Appeals (OMHA)
  • Minimum amount in controversy: $180 (2024)
  • Deadline to file: 60 days from Level 2 decision

Level 4: Medicare Appeals Council

  • Who reviews: Departmental Appeals Board
  • Deadline to file: 60 days from Level 3 decision

Level 5: Federal District Court

  • Minimum amount in controversy: $1,840 (2024)
  • Deadline to file: 60 days from Level 4 decision

Medicare Advantage (Part C) Appeals

  • Similar 5-level structure but starts with the MA plan
  • Plan has 30 days (standard) or 72 hours (expedited) for initial reconsideration
  • If denied, automatically forwarded to Independent Review Entity (IRE)

Key Tips

  1. Always appeal — Medicare appeal success rates are significant
  2. 1-800-MEDICARE (1-800-633-4227) for assistance
  3. State Health Insurance Assistance Program (SHIP) provides free counseling
  4. Medicare Rights Center: 1-800-333-4114
  5. Request expedited appeals for urgent health situations

Need Help Writing Your Appeal?

Our AI-powered tool analyzes your denial letter and generates a personalized appeal in minutes. Upload your denial and get started for free.

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Frequently Asked Questions

What is the Medicare appeal success rate?

Medicare appeal success rates vary by level, but a significant percentage of denials are overturned. At the ALJ level, success rates have historically been above 50%. This is why it's always worth appealing.

Can I get help with my Medicare appeal for free?

Yes. The State Health Insurance Assistance Program (SHIP) provides free counseling and help with Medicare appeals in every state. Call 1-800-MEDICARE to find your local SHIP.

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