The numbers behind a Medicare appeal
Here's what to do, in 4 steps.
Here's the order I'd work in. The first deadline is the most important one — you have one hundred twenty days from the day you receive your Medicare Summary Notice to file a Redetermination if you're in Original Medicare. Miss that and you're asking for a good-cause exception you may not get.
-
Read the denial notice carefully
Find your Medicare Summary Notice (Original Medicare) or your plan's denial letter (MA/Part D). The notice tells you which track you're on, the reason for denial, the appeal deadline, and where to send your appeal. Note the date you received it — your clock starts that day.
Time: 30 minutes Cost: Free Medicare appeals overview
-
File a Redetermination within 120 days
If you're in Original Medicare, mail or fax your Redetermination request to the Medicare Administrative Contractor (MAC) listed on your MSN within 120 calendar days of the day you received the notice. If you're in MA, request reconsideration from your plan within 60 days. If you're in Part D, request a coverage determination first; redetermination from the plan is then within 60 days of that denial.
Time: 1–2 hours Cost: Free Redetermination request form (CMS-20027)
-
Document everything in one folder
Keep the original denial notice, your written appeal, proof of mailing, any clinical records that support medical necessity, doctor's letters, and every piece of correspondence you receive. If your appeal goes past the first level, the QIC, ALJ, and Council all look at the same record — build it once, build it well.
Time: Ongoing Cost: Free OMHA appellant resources
-
Get free help from SHIP
Call SHIP at 1-877-839-2675 — every state has trained, unbiased counselors who help with Medicare appeals at no cost. They walk you through which track applies to your situation, what evidence to gather, and how to draft your written appeal. They handle the early levels free; if you reach ALJ on a high-value claim, they can also point you to legal aid or a healthcare attorney.
Time: Same day Cost: Free Find your local SHIP
Dr. Ed explains Medicare appeals
Video coming soon
I'm filming a walkthrough of the five-level Original Medicare appeal architecture, the Medicare Advantage track, and the Part D track. The deadlines are different on each one and the deadlines are the trap.
Which of these sounds more like you?
Three different appeal tracks live under one Medicare. Find the one that fits — Original Medicare, Medicare Advantage, or Part D — and you'll know your first deadline.
I'm in Original Medicare and got a denied claimMedicare Summary Notice (MSN) shows a denied service or claim
You're on the five-level Original Medicare track. Level 1 is Redetermination by the Medicare Administrative Contractor (MAC) that processed your claim. You have 120 calendar days from the day you received your MSN to file. This is a written request — the form is CMS-20027 but a letter works too. The MAC must decide within 60 days.
If the MAC affirms the denial, you have 180 days to escalate to a Qualified Independent Contractor (QIC) for Reconsideration. If the QIC affirms, the next stop is an ALJ hearing at OMHA — you have 60 days, and the 2026 amount-in-controversy threshold is $200.
I'm in Medicare Advantage and my plan denied a serviceMA plan issued an organization determination denying coverage
Medicare Advantage runs a different first-level track. You request reconsideration directly from your plan within 60 days of receiving the organization determination. The plan must decide within 30 calendar days for service requests (or 60 days for payment requests).
If the plan affirms its denial in whole or in part, the case is automatically forwarded to an Independent Review Entity (IRE) contracted by CMS. From the IRE forward, MA appeals merge with Original Medicare — ALJ hearing at OMHA, then Medicare Appeals Council, then federal court. Same 2026 amount-in-controversy thresholds apply: $200 for ALJ, $1,960 for federal court.
My Part D plan denied a drug I needPart D plan denied a coverage determination or tier exception
Part D appeals start with a coverage determination from your plan — that includes formulary exceptions and tier exceptions. If the plan denies, you (or your prescriber on your behalf) request a redetermination from the same plan within 60 days of the denial.
The plan must decide a standard redetermination within 7 calendar days for benefit requests (14 days for payment). If your prescriber documents that the standard timeline could seriously jeopardize your health, you can request expedited redetermination — the plan must decide within 72 hours.
If the plan affirms denial, the next levels are IRE → ALJ → Medicare Appeals Council → federal court, same as MA.
I think the hospital is discharging me too soonHospital issued discharge notice and you don't think you're ready
Hospital discharge appeals run on a separate, much faster track — the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). You request the expedited determination by phone or in writing no later than the day of discharge. The QIO must decide within one calendar day after it receives all the records it needs.
While the QIO reviews, the hospital can't bill you for the disputed days. If the QIO sides with the hospital, you can request a QIC expedited reconsideration by noon the next day — the QIC has 72 hours to decide.
My SNF or home health is ending Medicare coverageSkilled nursing or home health agency issued a termination notice
Skilled nursing facility (SNF), home health, hospice, and CORF terminations also run through the QIO on an expedited timeline. You request the expedited determination by no later than noon of the calendar day after you receive the termination notice. The QIO must decide within 72 hours of receiving the request.
This is the most-missed appeal opportunity I see. The notice format — a Notice of Medicare Non-Coverage (NOMNC) — looks routine, and people sign it without realizing they had two days to challenge.
I missed the appeal deadline — is it over?Past 120 days for Original Medicare or 60 days for MA/Part D
Not necessarily. CMS rules let the contractor (or plan, or QIC) extend the filing deadline if you show "good cause." The regulation lists specific examples — serious illness, death in the family, destroyed records, the contractor gave you wrong information, you didn't receive the notice, or you sent the appeal to the wrong government office in good faith.
File the appeal anyway. Attach a written statement explaining why you missed the deadline and any evidence you have (medical records, postmarked envelope, hospital admission dates).
I'm helping a parent appeal a Medicare denialYou're the family member or caregiver doing the paperwork
You can do most of the legwork — reading the notice, gathering records, drafting the appeal — but the appeal has to be filed by your parent or by an Authorized Representative on file with Medicare. The form for that is CMS-1696 (Appointment of Representative). You and your parent both sign it; it's good for one year.
The deadlines run from the date your parent received the notice, not the date you found out about it. If your parent has cognitive decline and can't sign, contact SHIP at 1-877-839-2675 — they can walk you through court-appointed representative options or how to use an existing power of attorney.
If your parent has Medicaid too, the dual-eligible page covers extra appeal rights. → See dual-eligible appeal rights
None of these match my situationYou're not sure which track applies, or it's something else
Some Medicare disputes don't follow the standard appeal architecture. Quality-of-care complaints (a doctor or hospital provided poor care) go to the BFCC-QIO directly — not through redetermination. IRMAA disputes (high-income premium surcharges) follow a Social Security appeal track, not the Medicare claims track. Late-enrollment penalties have their own reconsideration process.
If you're not sure which track applies, call SHIP at 1-877-839-2675. They handle every Medicare appeal type at no cost and will tell you within ten minutes which form, which deadline, and where to send it.
If you're disputing IRMAA or a late-enrollment penalty, those have their own pages. → See IRMAA and LEP appeal pages
Everything people ask me about Medicare appeals
How long do I have to appeal a Medicare denial?
It depends on your track. Original Medicare: 120 calendar days from the date you receive your Medicare Summary Notice to file a Redetermination (42 CFR 405.942). Medicare Advantage: 60 days from the plan's organization determination. Part D: 60 days from the plan's coverage determination. The clock starts the day you receive the notice (CMS presumes 5 days after the notice date unless you can prove otherwise).
What are the five levels of Original Medicare appeal?
Level 1: Redetermination by the Medicare Administrative Contractor (120 days to file). Level 2: Reconsideration by a Qualified Independent Contractor (180 days). Level 3: ALJ hearing at the Office of Medicare Hearings and Appeals (60 days; 2026 amount-in-controversy threshold is $200). Level 4: Medicare Appeals Council review (60 days). Level 5: Federal District Court (60 days; 2026 amount-in-controversy threshold is $1,960).
Do I need a lawyer to appeal Medicare?
No, not at the early levels. Redetermination is a written request you can file yourself, and SHIP counselors will walk you through it for free. Most appeals are resolved before they ever reach an ALJ. If your case escalates to ALJ or federal court — especially on a high-value claim above $200 (2026 ALJ threshold) or $1,960 (federal court) — a healthcare attorney becomes worth considering.
What does it cost to appeal Medicare?
Filing an appeal at any level of the Medicare appeals process is free — there is no filing fee. SHIP help is free. The only costs you might incur are private attorney fees if you choose to hire one (typically at the ALJ level or higher) and any costs for medical-record copies your providers may charge.
How are Part D appeals different from Original Medicare appeals?
Part D appeals start with a coverage determination from your plan (this is where you'd request a formulary or tier exception). If denied, you request redetermination from the same plan within 60 days. The plan must decide within 7 calendar days for a benefit request (14 days for payment), or 72 hours for an expedited request. From there, denied appeals go to the Independent Review Entity (IRE), then ALJ, Council, and federal court.
What's an expedited appeal and when can I request one?
An expedited appeal compresses the decision timeline because waiting could seriously jeopardize your health. In Medicare Advantage and Part D, the plan must decide an expedited request within 72 hours. Your prescriber or treating physician documents the medical urgency. Expedited reconsideration is available for service requests — not for payment-only disputes after the service is already received.
What if I missed the appeal deadline?
File the appeal anyway with a written explanation of why you missed the deadline. CMS rules at 42 CFR 405.942(b) allow a contractor to extend the filing deadline for "good cause" — examples include serious illness, death in the family, destroyed records, the contractor giving you wrong information, not receiving the notice, or sending it to the wrong government office in good faith. Attach any evidence you have.
How do I appeal a hospital discharge that feels too soon?
Hospital discharges run on a separate fast track. By no later than the day of discharge, call the BFCC-QIO listed on your Important Message from Medicare (IM notice). The QIO must decide within one calendar day of receiving all the records. While the QIO reviews, the hospital cannot bill you for the disputed days. If the QIO sides with the hospital, you can request expedited QIC reconsideration by noon the next day; the QIC has 72 hours.
What about a SNF or home health discharge — is that the same?
Same architecture, slightly different timing. When a skilled nursing facility, home health agency, hospice, or CORF gives you a Notice of Medicare Non-Coverage (NOMNC), you have until noon the next day to request an expedited determination from the QIO. The QIO must decide within 72 hours. While the QIO reviews, the provider can't bill you. This is the most-missed appeal opportunity I see — the NOMNC looks routine, and most people sign and walk away.
Can someone appeal on my behalf?
Yes. To have a family member, friend, or attorney act for you, file a CMS-1696 Appointment of Representative form alongside your appeal. Both you and the representative sign it; it's good for one year. A power of attorney by itself doesn't automatically count for Medicare — CMS wants its own form. If you can't sign because of a medical condition, SHIP at 1-877-839-2675 can walk you through court-appointed representative options.
Other programs that may help while you appeal
If a Medicare denial is squeezing your budget, other programs may step in. SHIP can help you appeal at no cost. Medicare Savings Programs and Extra Help reduce premiums and drug costs. Medicaid may pay what Medicare won't. Check the ones that fit.
SHIP — free Medicare appeal help
Every state has a State Health Insurance Assistance Program with trained counselors who help with every Medicare appeal type at no cost. Call 1-877-839-2675 to find your local SHIP.
Medicare Savings Programs (QMB / SLMB / QI)
If a Medicare denial is straining your budget, you may qualify for a Medicare Savings Program. QMB pays your Part B premium plus most cost-sharing; SLMB and QI pay the Part B premium. Check with your state Medicaid office.
Extra Help (Part D Low-Income Subsidy)
If your Part D denial involves drug costs you can't afford, you may qualify for Extra Help. The program reduces or eliminates Part D premiums, deductibles, and copays. Apply through Social Security or your state Medicaid office.
Medicaid (full or dual-eligible)
If you're income-eligible for full Medicaid, it may pay for what Medicare denied (especially long-term care, dental, vision). Dual-eligibles also have additional appeal rights through their state Medicaid agency.
Medicare Beneficiary Ombudsman
If your appeal is stuck or you're getting the runaround from a contractor or plan, the Medicare Beneficiary Ombudsman takes complaints and helps escalate. Federally funded; free.
State legal aid or healthcare attorney
If your appeal reaches the ALJ level on a high-value claim, you may qualify for free state legal aid (income-based) or want to talk to a healthcare attorney. SHIP can refer you locally.
Help me keep it.
If you want plain-English explainers when Medicare appeal rules change — new amount-in-controversy thresholds, new deadlines, new Part D rules — give me your email. I write a short note when something actually moves.
Visual placeholder only. This staging build does not submit data. I never share your email. Unsubscribe with one click.