Understanding the 5 Levels of Medicare Appeals

Receiving a Medicare denial can feel like a dead end, but it is not. The Medicare program has a formal, structured appeals process with 5 distinct levels to ensure your case gets a fair review. Understanding each level is the key to successfully navigating the system and fighting for the coverage you deserve.

Here is a simplified breakdown of the 5 administrative appeal levels.

Level 1: Redetermination or Reconsideration

This is your first chance to challenge a denial. The review is conducted by the same entity that issued the initial denial, but by a different person.

  • Original Medicare (Parts A and B): The appeal is called a Redetermination and is reviewed by the Medicare contractor. The deadline to file is 120 days from the date on your Medicare Summary Notice (MSN).

  • Medicare Advantage (Part C) and Part D: The appeal is a Reconsideration (Part C) or Redetermination (Part D), reviewed by your plan. The deadline to file is 60 days from the date on your denial notice.

Level 2: Independent Review

If you receive an unfavorable decision at Level 1, your case moves to an independent reviewer not associated with your plan or the initial contractor.

  • Original Medicare (Parts A and B): This appeal is a Reconsideration and is reviewed by a Qualified Independent Contractor (QIC). The deadline to file is 180 days from the date on your Level 1 decision notice.

  • Medicare Advantage (Part C) and Part D: This appeal is a Reconsideration and is reviewed by an Independent Review Entity (IRE). The deadline to file is 60 days from the date on your Level 1 decision notice.

Level 3: Hearing Before an Administrative Law Judge (ALJ)

This is a significant step where you get to present your case to a federal judge within the Office of Medicare Hearings and Appeals (OMHA).

  • You must meet the annually adjusted "Amount in Controversy" requirement to proceed to this level.

  • The deadline to request a hearing is 60 days from the date on your Level 2 decision notice.

  • Hearings are typically conducted by phone or video-conference.

Level 4: Medicare Appeals Council Review

If the ALJ's decision is unfavorable (you did not get what you wanted), you can request a review from the Medicare Appeals Council. This is the final level of review within the Department of Health and Human Services.

  • The Council typically reviews the existing administrative record for errors of law or fact. They usually do not hold a new hearing.

  • The deadline to file is 60 days from the date on your ALJ decision notice.

Level 5: Judicial Review in U.S. District Court

This is the final option to challenge a denial, taking your case outside the administrative system and into a Federal Court.

  • You must again meet a specific "Amount in Controversy" requirement to file a lawsuit in U.S. District Court.

  • This step is complex and almost always requires the assistance of an attorney.