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Appeals in Medicare health plans
Before you start an appeal, ask your provider or supplier for any information to make your appeal stronger.
Program of All-inclusive Care for the Elderly (PACE) A special type of health plan that provides all the care and services covered by Medicare and Medicaid as well as additional medically necessary care and services based on your needs as determined by an interdisciplinary team. PACE serves frail older adults who need nursing home services but are capable of living in the community. PACE combines medical, social, and long-term care services and prescription drug coverage.
, your appeal rights are different. The PACE organization will give you written information about your appeal rights. Learn more about PACE plans.
Appeals in a Cost plan
Medicare Cost plans are types of HMOs available in certain areas of the country. If you have a Medicare Cost plan and want to appeal services you got outside of the plans network, you’ll need to follow the Original Medicare appeals process.
Appeals in a Medicare Advantage plan
There are 5 levels of appeals. If you disagree with the decision made at any level of the process, you can generally go to the next level. At each level you'll get a decision letter with instructions on how to move to the next level of appeal.
Coverage decisions in a Medicare Advantage Plan are called “Organization Determinations.” When you’re in a plan, you have the right to an organization determination, either orally or written, to find out if a service, drug, or supply is covered.
Contact your plan to get an organization determination and follow the instructions to file a timely appeal if you disagree with the decision.
If a plan provider refers you for a covered service or to a provider outside the network, but doesn’t get an organization determination in advance, this is called “plan directed care.” In most cases, you won’t have to pay more than the plan’s usual cost sharing. Check with your plan for more information about this protection.
How do I start an appeal?
Level 1 appeals in a Medicare Advantage Plan are called “Health Plan Reconsiderations.” If you disagree with the initial decision from your plan, you or your representative can ask for a reconsideration. Follow the directions in the plan's initial denial notice and plan materials to start your appeal. If your appeal is for a service you haven’t gotten yet, your doctor can ask for a reconsideration on your behalf (and must notify you about it).
You, your representative, or your doctor or healthcare provider must file an appeal within 65 days from the date on the initial denial notice sent by your plan. If you miss the deadline, you must give a reason for filing late.
The items or services you’re appealing, the dates of service, and the reason(s) why you're appealing.
The name of your representative and proof of representation, if you’ve appointed a representative.
Any other information (like a doctor’s note) to make your appeal stronger.
If you think your health could be seriously harmed by waiting the standard 30 days for a decision, ask your plan for a fast or "expedited" appeal. The plan must give you its decision within 72 hours if it determines, or your doctor tells your plan, that waiting for a standard decision may seriously jeopardize your life, health, or ability to regain maximum function.
How long your plan has to respond to your initial appeal depends on the type of appeal you’re filing:
Standard process:
Pre-service appeal: 30 days
Payment appeal: 60 days
Part B drugs appeal: 7 days
Fast appeal: 72 hours
The time to complete appeals may be extended by up to 14 days in some cases. For example, if your plan needs more information from a non-contract provider to make a decision about your case, and the extension is in your best interest. Your plan will notify you in writing if it decides to take an extension, why, and your rights if you disagree with their decision.
If the plan decides against you (fully or partially), your appeal is automatically sent to level 2.
If your plan upholds their denial in your level 1 appeal, they’ll automatically forward their reconsideration decision to an Independent Review Entity (IRE) to start a level 2 appeal.
How long the IRE has to respond depends on the type of appeal.
Standard process:
Pre-service appeal: 30 days
Payment appeal: 60 days
Part B drugs: 7 days
Fast appeal: 72 hours
The time to complete appeals may be extended by up to 14 days in some cases. For example, if your plan needs more information from a non-contract provider to make a decision about the case, and the extension is in your best interest. Your plan will notify you in writing if it decides to take an extension, why, and your rights if you disagree with the plan’s decision to take an extension.
You'll get a fast decision if the IRE determines that your life or health may be at risk by waiting for a decision.
If you disagree with the IRE's decision in level 2:
You have 60 days from the date of the IRE’s decision to ask for a level 3 appeal, which is a decision by the Office of Medicare Hearings and Appeals (OMHA).
If you file an appeal with OMHA the amount of your case must meet a minimum dollar amount. For 2024, the minimum dollar amount is $180.
You can ask for a hearing before an Administrative Law Judge (ALJ) or, in certain circumstances, if you don’t want to have a hearing, you can ask for an on the record review of your appeal by an ALJ or attorney adjudicator. To ask for a hearing before an ALJ, follow the directions on the "Medicare Reconsideration Notice" you got from the Qualified Independent Contractor (QIC) in your level 2 appeal.
A hearing before an ALJ allows you to present your appeal to a new person who will independently review the facts of your appeal and listen to your testimony before making a decision. An ALJ hearing is usually held by phone or video-teleconference, but can also be held in person if the ALJ finds that you have a good reason.
You or your representative can ask for a hearing in one of these ways:
Your name, address, phone number, and Medicare Number. If you've appointed a representative, include the name, address, and phone number of your representative.
The appeal number assigned by the QIC if any.
The dates of service for the items or services you're appealing.
Why you disagree with the QIC's decision.
Any information to make your appeal stronger. If you can't include this information with your request, include a statement explaining what you plan to submit and when you'll submit it.
Get more information about the ALJ hearing process or call us at 1-800-MEDICARE (1-800-633-4227).
How do I ask for a review of my case without a hearing?
You can ask OMHA to make a decision without holding a hearing (based only on the information that's in your appeal record). The ALJ or attorney adjudicator may also issue a decision without holding a hearing if the appeal record supports a decision that's fully in your favor.
To ask OMHA to make a decision without a hearing (based on only the information that's in your appeal record), submit the information required for an ALJ hearing (listed above) and one of these:
A written request stating that you don't wish to appear before an ALJ at a hearing (including a hearing held by phone or video-teleconference).
Even if you waive the ALJ hearing, a hearing may still be held by an ALJ if the other parties in your case who were sent a notice of hearing (for example, your provider) don’t also waive the ALJ hearing, or if the ALJ believes a hearing is necessary to decide your case.
If you asked OMHA for a decision without a hearing, but the ALJ decides a hearing is necessary, the ALJ will let you know when the hearing will be. If no hearing is held, either an ALJ or attorney adjudicator will review the information in your appeal record and make a decision.
You can ask to move to appeals level 4 if:
OMHA doesn't issue a timely decision.
You disagree with the OMHA's decision.
You have 60 days after you get the decision to move to appeals level 4, by asking for a review by the Medicare Appeals Council (Appeals Council).
Submit a written request to the Appeals Council that includes:
Your name and Medicare Number. If you've appointed a representative, include the name of your representative.
The specific item(s) and/or service(s) and specific date(s) of service you're appealing.
A statement describing what you disagree with in the ALJ's decision and why.
The date of the ALJ decision.
If you're asking that your case be moved from the ALJ to the Appeals Council because the ALJ hasn't issued a timely decision, send your ask to the OMHA address listed on the QIC's reconsideration notice (or if you know that your case was assigned to an OMHA adjudicator, to the hearing office where it’s pending).
For more information about the Appeals Council review process, visit HHS.gov, or call us at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
You can request judicial review in Federal district court (level 5) if:
The Appeals Council doesn't issue a timely decision.
You disagree with the Appeals Council's decision in level 4.
The amount of your case meets a minimum dollar amount. For 2024, the minimum dollar amount is $1,840. You may be able to combine claims to meet this dollar amount.
You have 60 days after you get the Appeals Council’s decision to ask for judicial review by a federal district court.
To get a judicial review in Federal district court, the amount of your case must meet a minimum dollar amount. For 2024, the minimum dollar amount is $1,840. You may be able to combine claims to meet this dollar amount.
Follow the directions in the Appeals Council’s decision letter you got in your level 4 appeal to file for judicial review in federal court.
Medicare Special Needs Plan (SNP) A special type of Medicare Advantage Plan (Part C) that provides more focused and specialized health care for specific groups of people, like those who have both Medicare and Medicaid, who live in a nursing home, or have certain chronic medical conditions.
(SNP), your plan must tell you in writing how to appeal. After you file an appeal, the plan will review its original decision. If your plan doesn't decide in your favor, the appeal is reviewed by an independent organization. The independent organization works for Medicare, not for the plan.
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