- If you disagree with a Medicare penalty, surcharge, or decision to not cover your care, you have the right to appeal.
- Original Medicare (parts A and B), Medicare Advantage (Part C), and Medicare Part D plans each have multiple levels of appeal.
- Notices from Medicare should inform you of the deadlines and documents that apply in your case.
- You can get help filing your appeal from your doctor, family members, attorneys, or advocates.
As a Medicare beneficiary, you have certain rights. One of them is the right to appeal a Medicare decision that you think is unfair or will jeopardize your health.
The Medicare appeals process has several levels. While the process can take time, it provides several opportunities to explain your position and provide documents to back up your claim.
In this article, we’ll go over the appeals process, the steps for filing an appeal, and tips for winning your appeal.
Medicare decides which services, medications, and equipment are covered. However, you may not always agree with Medicare’s decisions.
If Medicare refuses to cover care, medication, or equipment that you and your healthcare provider think are medically necessary, you can file an appeal.
You may receive a form called an Advance Beneficiary Notice of Noncoverage (ABN). This form usually comes from your healthcare provider and lets you know that you — not Medicare — are responsible for paying for a service or equipment.
This notice may have another name, depending on the type of provider it comes from.
Sometimes, Medicare may let you know that it’s denying coverage for a service, medication, or piece of equipment after you’ve received that service, medication, or piece of equipment.
In this case, you’ll receive a Medicare summary notice, which will let you know that Medicare didn’t fully cover a benefit you received.
In addition to telling you Medicare won’t cover or hasn’t covered your services, these documents should explain the reasons behind Medicare’s decision. You should also receive instructions for how to appeal the decision if you disagree with it or think there was an error.
If you disagree with a Medicare determination, you have multiple chances to resolve the conflict. There are five levels of appeal for services under original Medicare, and your claim can be heard and reviewed by several different independent organizations.
Here are the levels of the appeal process:
- Level 1. Your appeal is reviewed by the Medicare administrative contractor.
- Level 2. Your appeal is reviewed by a qualified independent contractor.
- Level 3. Your appeal is reviewed by the Office of Medicare Hearings and Appeals.
- Level 4. Your appeal is reviewed by the Medicare Appeals Council.
- Level 5. Your appeal is reviewed by a federal district court.
As you can see, if your appeal isn’t successful the first time, you can continue to the next levels. However, it may take patience and perseverance. The good news is that if you proceed to the third level of appeal, you have a much better chance of success.
At every decision level, you’ll receive instructions on how to proceed to the next level of appeal if you disagree with the most recent decision. The instructions will include information about where, when, and how to move to the next appeal level.
Next, we’ll guide you through each step of the process.
File a written request asking Medicare to reconsider its decision.
You can do this by writing a letter or by filing a Redetermination Request form with the Medicare administrative contractor in your area. The address should be listed on your Medicare summary notice.
If you send a letter, include the following information in your request:
- your name and address
- your Medicare number (as shown on your Medicare card)
- the items you want Medicare to pay for and the date you received the service or item
- the name of your representative if someone is helping you manage your claim
- a detailed explanation of why Medicare should pay for the service, medication, or item
You should receive an answer through a Medicare redetermination notice within 60 days.
If the Medicare administrative contractor denies your claim, you can proceed to the next level of appeal. Your redetermination notice will list the instructions for filing this appeal.
You can file a third appeal with the qualified independent contractor in your area. You must do this within 180 days of the date shown on the redetermination notice.
Update any medical records if necessary and submit your request for reconsideration in writing. You can use the Medicare Reconsideration Request form or send a letter to the address shown on your Medicare redetermination notice.
You should have a response from the qualified independent contractor within 60 days. If they didn’t decide in your favor, you can ask for a hearing before an administrative law judge or an attorney adjudicator at the Office of Medicare Hearings and Appeals.
If the qualified independent contractor didn’t return a decision to you within the 60-day timeframe, you can escalate your claim to the Office of Medicare Hearings and Appeals.
In this case, you should receive a notice from the qualified independent contractor letting you know that your appeal won’t be decided in the set time period.
The Office of Medicare Hearings and Appeals should issue a decision in 90 to 180 days. If you don’t agree with the decision, you can apply for a review by the Medicare Appeals Council.
You’ll need to make the request in writing or submit a Request for Review of Administrative Law Judge (ALJ) Decision within 60 days of the Office of Medicare Hearings and Appeals decision.
You can also file your appeal electronically.
If the decision of the Medicare Appeals Council isn’t in your favor, you can present your case to a judge in federal district court. The amount of money you’re asking Medicare to pay must meet a set amount to proceed with an appeal in court.
If the council informs you that it can’t come to a decision in the required period of time, you can escalate your case to federal court.
To take your appeal to the next level, you’ll need to file suit in federal court within 60 days of the council’s decision.
Be aware that at any point during the appeals process, Medicare may attempt to reach a settlement with you.
Here’s a quick guide to the appeals process for original Medicare claims:
|What form do I use to start the appeal?||How do I file an appeal?||How long do I have to file an appeal?||How long does the review board take to decide?||What else do I need to know?|
|First appeal: Medicare administrative contractor||CMS Form 20027 or written request||U.S. mail or online portal||120 days from the date of denial (summary notice or remittance advice)||60 days||—|
|Second appeal: qualified independent contractor||CMS Form 20033 or written request||U.S. mail or online portal in your region||180 days from the date of the redetermination (summary notice, redetermination notice, or remittance advice)||60 days||If you submit supporting documents after your appeal, the QIC may take extra time to review them.|
|Third appeal: Office of Medicare Hearings and Appeals||Form OMHA-100, Form OMHA-104, or written request||U.S. mail to the address shown on your reconsideration decision||60 days from the date of the decision||90–180 days||If you submit extra documents, the Office of Medicare Hearings and Appeals may extend the timeframe for its response. Appeals are currently backlogged.|
|Fourth appeal: Medicare Appeals Council||DAB-101 or written request||U.S. mail to the address shown on your OMHA decision or by fax to 202- 565-0227||60 days from the date of the decision||usually 180 days||The council receives a year’s worth of appeals every 2.5 months. You should expect a delayed response.|
|Fifth appeal: federal district court||forms for filing suit in federal court||need to file a lawsuit in federal court||60 days from the date of the decision||no timeline||—|
Medicare Part C (Medicare Advantage) and Medicare Part D are private insurance plans. When you enrolled in these plans, you should’ve received a guide informing you about your rights and the appeals process.
You can consult this guide or talk to your plan administrator to get details about how to proceed through the appeals process for your specific plan.
Here’s an overview of how the appeals process looks for Medicare Advantage and Part D:
|How do I start the appeal?||How do I file the appeal?||How long do I have?||When should I expect a decision?||What else should I know?|
|First appeal: reconsideration request||contact your plan; request a review of the original coverage determination||follow the guidelines in your plan||60 days from the original determination by your plan||72 hours for an expedited appeal; 30 days for a standard appeal; 60 days for a payment request||Expedited appeals are for cases when a delay could endanger your life, health, or ability to fully recover.|
|Second appeal: independent review entity||if your claim is denied at the first level, it is automatically sent to the independent review entity||if your claim is denied at the first level, it is automatically sent to the independent review entity||10 days from your plan’s reconsideration decision (for you to send additional information to the independent review entity)||72 hours for an expedited appeal; 30 days for a standard appeal; 60 days for a payment request||Some IREs are also known as “Part C QICs.”|
|Third appeal: Office of Medicare Hearings and Appeals||Form OMHA-100, Form OMHA 104 or written request||U.S. mail to the address shown on your independent review entity decision||60 days from independent review entity decision||usually 90–180 days, though the appeals are currently backlogged||The required minimum amount at this appeal level is $170. If the OMHA decides in your favor, your plan can appeal to the next level.|
|Fourth appeal: Medicare Appeals Council||DAB-101 or written request||U.S. mail to the address shown on your OMHA decision or by fax to 202-565-0227||60 days from the OMHA decision||usually 180 days||If you submit your appeal via fax, you don’t need to send an additional mail copy.|
|Fifth appeal: federal court||forms for filing suit in federal court||need to file a lawsuit in federal court||60 days from Medicare Appeals Council decision||no timeline||—|
If your health will be harmed by a longer appeals process, you can request a fast-tracked (expedited) appeal. We’ll go over two common scenarios when you might need to file a fast appeal.
If your care is ending
If you’ve received notice that a hospital, skilled nursing facility, home health agency, rehabilitation facility, or hospice facility is going to end your care, you have a right to a quicker appeals process.
The federal government requires hospitals and other inpatient care facilities to notify you before your services are going to end.
As soon as you receive notice that you’re being discharged, contact the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). Contact information and instructions for filing an appeal are included in the notice.
If you’re being treated in a hospital, you must request a fast appeal by the date you’re supposed to be discharged.
Once the qualified independent contractor has been informed you want to appeal the decision to end your care, it will review your circumstances and make a decision, usually within 24 hours. If the qualified independent contractor doesn’t decide in your favor, you won’t be charged for the extra day in the facility.
You can appeal the denial, but you must file an appeal by 12:00 p.m. on the day after the decision is made.
If your care is being decreased
If you’re being treated in a skilled nursing facility or a home health agency, the facility may notify you that Medicare won’t pay for a portion of your care, and they plan to reduce your services.
If that happens, you’ll receive one of the following:
- a Skilled Nursing Facility Advance Beneficiary Notice
- a Home Health Advance Beneficiary Notice
- a Notice of Medicare Noncoverage
If you have a Medicare Advantage plan, you’ll need to contact your plan and follow the guidelines for filing an expedited appeal.
If you have original Medicare, you have three options:
- Ask for “demand billing.” That’s where you continue to receive care until the healthcare provider bills Medicare and Medicare denies coverage. If Medicare won’t cover your care, you can start the appeals process then.
- Pay for your continued care out of pocket.
- End care from your current provider and find another provider to treat you.
A home health agency might deny your request for demand billing if:
- Your doctor thinks you no longer need care.
- They don’t have enough staff to continue your treatment.
- It isn’t safe for you to be treated in your own home.
If you believe you’ve been unfairly denied access to healthcare that you need, you should use your right to appeal. To increase your chance of success, you may want to try the following tips:
- Read denial letters carefully. Every denial letter should explain the reasons Medicare or an appeals board has denied your claim. If you don’t understand the letter or the reasons, call 800-MEDICARE (800-633-4227) and ask for an explanation. Denial letters also contain instructions on how to file your appeal.
- Ask your healthcare providers for help preparing your appeal. You can ask your doctor or healthcare provider to explain your condition, circumstances, or needs in a letter that you can submit with your appeal. You can also ask your healthcare providers to give you any supporting documentation that supports your claim.
- If you need help, consider appointing a representative. An advocate, friend, doctor, attorney, or family member can help you manage your appeal. If you want assistance in preparing your Medicare appeal, you will need to complete an Appointment of Representative form. If you communicate with Medicare in writing, name your representative in the letter or e-mail.
- Know that you can hire legal representation. If your case goes beyond an initial appeal, it may be a good idea to work with a lawyer who understands Medicare’s appeals process so your interests are properly represented.
- If you are mailing documents, send them via certified mail. You can request a return receipt, so that you have a record of when Medicare received your appeal.
- Never send Medicare your only copy of a document. Keep copies of all important documents for your records.
- Keep a record of all interactions. If you speak with a Medicare representative, document the date, time, and information received during call for your records.
- Create a calendar or timeline. Because each phase of the appeals process has its own deadlines, it may help to track each of them on a calendar. If you miss a deadline, your appeal may be denied or dismissed. If there’s a good reason to extend your deadline, you can apply for a good cause extension.
- Follow your progress. If your appeal is before the Office of Medicare Hearings and Appeals, you can check the status of your appeal here.
- Don’t give up. Medicare appeals take time and patience. Most people stop trying after the first denial.
If you have questions or need help with a Medicare appeal, you can contact your State Health Insurance Assistance Program for unbiased advice. This service is free and is provided by trained local volunteers.
You have rights and protections when it comes to Medicare. If you don’t agree with a decision made by original Medicare, your Medicare Advantage plan, or your Medicare Part D prescription drug plan, you can appeal.
Medicare plans have five levels of appeals, ranging from a simple request, to reconsideration, all the way up to a lawsuit in federal court.
You must carefully follow the deadlines and appeal instructions provided in any notice you receive. If you miss deadlines or don’t supply documentation to back up your claim, your claim could be denied or dismissed.
You’re allowed to appoint a representative to help you file and manage your appeals. Consider asking for help, especially if a health condition prevents you from devoting enough time to the appeals process.
Filing a Medicare appeal can be time consuming, and decisions can sometimes take months. Ultimately, the appeals process helps to safeguard your rights and ensure you get the care that you and your healthcare providers think you need.