How a Medicare appeal works: the five levels, and the clock on each one

If Medicare or your plan won't cover a service, won't pay for one you already received, or changes what you owe, you can ask for that decision to be reviewed. Medicare describes the ground plainly on its filing an appeal page: you can appeal when Medicare or a plan refuses to cover an item or service, refuses to pay for one you already got, or changes the amount you must pay — and also when coverage you're currently receiving is stopped.

There are generally five levels. If you disagree with the decision at one level, you can usually go to the next, and every decision letter tells you how. What differs — and this is the part worth knowing before you need it — is the calendar.

Original Medicare: it starts with a notice in the mail

Level one is called a redetermination, and it begins with your Medicare Summary Notice. Medicare's appeals in Original Medicare page walks the sequence: you file by the date printed on the MSN, sending a Redetermination Request Form or a written request to the Medicare Administrative Contractor whose address appears on the notice's last page. The contractor generally decides within 60 days of receiving it.

If that decision goes against you, you have 180 days from the decision letter to ask for level two, a reconsideration by a Qualified Independent Contractor — a reviewer that took no part in the first decision. Levels three, four, and five move outside the claims-processing world: a hearing before an administrative law judge, review by the Medicare Appeals Council, and finally review in federal district court, where the amount in dispute must meet a minimum set each year.

Missing a deadline isn't automatically the end. Medicare notes that a late appeal can still be decided if you can show good cause — an illness, a disability, or an accident that delayed you.

Medicare Advantage: different names, different clocks

In a Medicare Advantage plan the first decision is called an organization determination, and you have the right to ask for one — orally or in writing — to find out whether something is covered before you get it. Medicare's page on appeals in Medicare health plans sets out what follows. Level one is a plan reconsideration, and you, your representative, or your doctor must file within 65 days of the date on the plan's denial notice.

The plan's response time depends on what you're appealing: 30 days for a service you haven't received yet, 60 days for a payment appeal, 7 days for a Part B drug, and 72 hours for a fast appeal. A fast appeal is available when waiting for the standard decision could seriously jeopardize your life, health, or ability to regain maximum function — your plan must grant it if your doctor says so. Some cases can be extended by up to 14 days, and the plan must tell you in writing why. The plan-level timeframes trace back to the regulations at 42 CFR §422.568 and §422.572.

One structural difference matters: if a Medicare Advantage plan decides against you in whole or in part at level one, your appeal is sent to level two automatically, to an independent review entity. You don't have to file it yourself.

When care is ending sooner than you expected

There is a separate track when Medicare-covered services are ending — from a hospital, skilled nursing facility, home health agency, rehabilitation facility, or hospice. Medicare describes this on its fast appeals page: your provider gives you a written notice before services end explaining how to request an immediate review. If you don't receive that notice, ask for it.

You don't have to do it alone

Two forms of help are built into the system. You can appoint a representative — a family member, a friend, a provider — using Medicare's Appointment of Representative form, so someone else can file and speak on your behalf. And every state has a State Health Insurance Assistance Program offering free, personalized counseling, which Medicare points to directly from its appeals pages.

What to keep

• The notice itself. The MSN or the plan's denial letter carries the deadline, the address, and the reason for the decision.
• The reason in writing. An appeal is stronger when it answers the stated reason rather than restating the request.
• Anything your provider can add — a note explaining medical necessity, records, prior treatment history. Medicare suggests asking before you file.
• The dates. 180 days at one step and 65 at another is exactly the kind of difference that's easy to assume away.

If you're reading a denial letter and can't tell which process you're in or what the deadline is, a licensed agent can walk through the notice with you — a free conversation, with no pressure.