Medicare Appeals Process – Denied Claims

Few experiences in retirement are more frustrating than receiving a denial from Medicare for a service your doctor ordered. But a denial is not the final word. Medicare has a formal, multi-level appeals process—and beneficiaries who appeal their denials win a significant portion of the time. Knowing how the process works can save you thousands of dollars in medical bills.

Before you appeal, it helps to understand why claims get denied in the first place. Common reasons include:

• Medicare determined the service was not "medically necessary"

• The provider or facility is not enrolled in Medicare

• The service isn't covered under your specific plan's benefits

• A required prior authorization wasn't obtained

• The claim contained billing errors or incorrect coding

• The service is considered experimental or investigational

Some denials are clear-cut; others are judgment calls that can legitimately be challenged with proper documentation.

Medicare provides five levels of appeal, and you must work through them in order. Each level has deadlines—missing a deadline can forfeit your right to appeal at that level.

Level 1: Redetermination

The first step is asking Medicare (or your Medicare Advantage plan) to review the decision again—called a redetermination. You must file within 120 days of receiving your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB). Submit your request in writing to the address shown on your MSN, along with any supporting documentation from your doctor explaining medical necessity.

Timeline: Medicare or your plan must respond within 60 days for Part A/B claims, or 7 days for urgent Medicare Advantage claims.

Level 2: Reconsideration by a Qualified Independent Contractor (QIC)

If the redetermination doesn't go your way, you can escalate to an independent review by a Qualified Independent Contractor—a company contracted by Medicare that is separate from your plan. You have 180 days from the redetermination decision to file. Again, submit all relevant medical records and a letter from your doctor supporting the medical necessity of the service.

Timeline: 60 days for standard appeals; 72 hours for expedited appeals involving urgent care.

Level 3: Office of Medicare Hearings and Appeals (OMHA)

If Level 2 doesn't resolve the issue—and the amount in dispute is at least $180 (in 2026)—you can request a hearing before an Administrative Law Judge. This level has more formal procedures. You can attend the hearing in person, by video, or by phone, and you can bring witnesses or legal representation. You have 60 days from the Level 2 decision to file.

This is where many successful appeals occur. Administrative Law Judges are independent and often overturn denials that were upheld at lower levels, particularly when clear medical documentation supports necessity.

Level 4: Medicare Appeals Council

If the ALJ rules against you, you can appeal to the Medicare Appeals Council—part of the Department of Health and Human Services. You have 60 days to file. The Council reviews the ALJ decision and the record and may affirm, reverse, or remand the case.

Level 5: Federal District Court

The final level is filing a lawsuit in federal district court. The amount in dispute must meet a threshold (approximately $1,860 in 2026). This level involves formal legal proceedings, so most beneficiaries who reach this point engage an attorney.

• Request an Itemized Bill from your provider and cross-reference it with your Medicare Summary Notice—billing errors are common and sometimes the source of the denial

• Get a letter from your doctor stating why the service was medically necessary and why alternatives were not appropriate—this is the single most important piece of documentation

• Keep copies of everything—every form you submit, every letter you receive, every date you file

• Request an expedited appeal if the denial involves care you currently need or are receiving—urgent appeals have much shorter turnaround times

• Contact your State Health Insurance Assistance Program (SHIP)—SHIP counselors can help you navigate the appeals process for free

• Don't wait to appeal. Missing a deadline means losing that level of appeal rights entirely

Many beneficiaries assume that appealing Medicare denials is futile. The data says otherwise. At the ALJ level (Level 3), beneficiaries win a significant percentage of cases—often because documentation that wasn't available at lower levels gets submitted, or because an independent reviewer applies a different standard than the original reviewer.

The lesson: a denial isn't a final answer. If your doctor ordered a service they believed was medically necessary, and Medicare denied it, the appeals process exists precisely for situations like yours. Use it.