What can I do if Medicare denies my claim or coverage?
A Medicare denial isn't the end of the road — it's the start of one. The appeal architecture has five levels and three different tracks (Original Medicare, Medicare Advantage, Part D), and most people give up before they even start the first one. They shouldn't.
Dr. Ed Weir, PhD · 20 years inside Social Security · "Former" Sergeant, USMC
Updated April 2026
What can I do if Medicare denies my claim or coverage?
If Medicare denies your claim or coverage, you have the right to appeal. Original Medicare runs through five levels (Redetermination, QIC Reconsideration, ALJ hearing, Medicare Appeals Council, federal court). Medicare Advantage and Part D follow different first-level tracks but converge at ALJ. The first level is a written request — no hearing, no lawyer, no fee.
Before you appeal, it can help to talk through your situation with a licensed Medicare advisor at no cost.
Free help from licensed Medicare advisors
Chapter's licensed Medicare advisors can walk you through what your denial notice means, which appeal track applies to your situation, and what evidence you'll need. They don't charge you anything, and they don't sell plans on this call. If your appeal sits in Medicare Advantage or Part D, they can also help you figure out whether your plan applied its own rules correctly.
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.
1. 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.
Medicare appeals overview ›2. 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.
Redetermination request form (CMS-20027) ›3. 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.
OMHA appellant resources ›4. Get free help from SHIP
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.
Find your local SHIP ›The numbers behind a Medicare appeal
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've seen people freeze when they get an MSN denial because the form looks bureaucratic. The first level is just a written request. No hearing, no lawyer, no fee. The win rate at higher levels rewards persistence — most of the people who get denied at Redetermination give up. Don't.
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.
If your MA plan denied a service you needed urgently, you can request an expedited reconsideration — the plan must decide within 72 hours. Ask your doctor to write that the standard timeline could seriously jeopardize your health.
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.
Don't get caught by this — if you skip the coverage-determination step and just argue with the pharmacist, you're not actually appealing. The clock doesn't start until you have a written denial from the plan. Ask your prescriber to file the coverage determination request first.
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.
Don't get caught by this — the hospital should give you an Important Message from Medicare (IM notice) within 2 days of admission and again within 2 days of discharge. If they didn't, your discharge clock may not have started. Tell the QIO the IM was missing.
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.
20 years at Social Security taught me — most people don't realize the NOMNC at the SNF or home-health agency is appealable. The provider hands it to you with a clipboard, you sign that you received it, and that signature isn't agreement. You still have until noon the next day to call the QIO. Look at the bottom of the notice for the QIO phone number.
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).
Good cause is decided case by case. If the contractor denies your good-cause request, that decision can also be reviewed at the next level. Don't assume "missed deadline" means "case closed."
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,
If you have a power of attorney for your parent, that doesn't automatically make you a Medicare Authorized Representative — CMS wants its own form. File the CMS-1696 with the appeal so the contractor can talk to you directly.
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 . 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 your situation is none of these, the safest move is to They're trained on every appeal type and the call is free.
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 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.
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 can walk you through court-appointed representative options.
Sources
Every figure and rule on this page is verified against primary sources. Last verified 2026-04-28.
- Any request for a Medicare Part A or Part B Redetermination must be filed within 120 calendar days from the date a party receives the notice of the initial determination. —ecfr.gov(verified 2026-04-28)
- Any request for QIC Reconsideration in Original Medicare appeals must be filed within 180 calendar days from the date the party receives the notice of the redetermination. —ecfr.gov(verified 2026-04-28)
- A request for an ALJ hearing or review of a QIC dismissal in Original Medicare appeals must be filed within 60 calendar days from the date the party receives notice of the QIC's reconsideration or … —ecfr.gov(verified 2026-04-28)
- A Medicare Advantage plan reconsideration request must be filed with the MA organization within 60 calendar days after receipt of the written organization determination notice. —ecfr.gov(verified 2026-04-28)
- A Medicare Advantage organization that approves a request for expedited reconsideration of a service or item must complete its reconsideration and notify the enrollee no later than 72 hours after … —ecfr.gov(verified 2026-04-28)
- A Medicare Advantage standard reconsideration of a service or item must be decided within 30 calendar days from the date the plan receives the request. —ecfr.gov(verified 2026-04-28)
- A Part D plan redetermination request must be filed with the Part D plan sponsor within 60 calendar days after receipt of the written coverage determination notice. —ecfr.gov(verified 2026-04-28)
- A Part D plan must complete a standard redetermination of a request for covered drug benefits no later than 7 calendar days from the date it receives the request. —ecfr.gov(verified 2026-04-28)
- A Part D plan must complete an expedited redetermination of a coverage request no later than 72 hours after receiving the request. —ecfr.gov(verified 2026-04-28)
- When a beneficiary requests an expedited determination of an inpatient hospital discharge, the QIO must make the determination and notify the beneficiary, hospital, and physician within one calendar … —ecfr.gov(verified 2026-04-28)
- For a non-residential provider termination (such as skilled nursing facility, home health, or CORF), the QIO must notify the beneficiary, beneficiary's physician, and provider of its expedited … —ecfr.gov(verified 2026-04-28)
- Filing deadlines for Medicare appeals may be extended for good cause, including serious illness, death in the family, destroyed records, the contractor giving incorrect information, the party not … —ecfr.gov(verified 2026-04-28)
- The amount-in-controversy threshold for ALJ hearings under Medicare appeals is computed from a $100 base, increased by the percentage increase in the medical care component of the consumer price index … —ecfr.gov(verified 2026-04-28)
- The 2026 amount-in-controversy threshold for Medicare ALJ hearings is $200, effective for requests filed on or after January 1, 2026. —federalregister.gov(verified 2026-04-28)
- The 2026 amount-in-controversy threshold for federal court judicial review of Medicare appeals is $1,960, effective for requests filed on or after January 1, 2026. —federalregister.gov(verified 2026-04-28)
Helping a parent appeal a Medicare denial?
If you're helping a parent or spouse appeal a Medicare denial, you'll want their Medicare Summary Notice (or plan denial letter), the date they received it, and either their signature on the appeal or a CMS-1696 Appointment of Representative form on file. The deadline runs from their receipt date — not yours.
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