How to Appeal a Medicare Denial: Your Rights and the Appeals Process
Medicare denies millions of claims every year -- and many of those denials are overturned on appeal. Here is how the Medicare appeals process works and how to fight a denial effectively.
How to Appeal a Medicare Denial: Your Rights and the Appeals Process
If Medicare denies a claim or refuses to cover a service, you have the right to appeal. And it's worth exercising that right -- studies show that a significant percentage of Medicare denials are overturned on appeal, especially when beneficiaries are persistent.
Why Medicare Denies Claims
Common reasons for Medicare denials:
- The service is deemed "not medically necessary"
- The provider is not enrolled in Medicare
- The claim contains billing errors
- The service requires prior authorization that wasn't obtained
- The service is considered experimental or investigational
- You've exceeded coverage limits (therapy caps, etc.)
The Five Levels of Medicare Appeals
Level 1: Redetermination
Who handles it: The Medicare Administrative Contractor (MAC) that processed the original claim.
Deadline: 120 days from receiving the initial denial.
How to file: Submit a written request to the MAC. Include your Medicare number, the date of service, the reason you disagree, and any supporting documentation (doctor's notes, medical records).
Timeline: The MAC must respond within 60 days.
Win rate: Approximately 30-40% of redeterminations are decided in the beneficiary's favor.
Level 2: Reconsideration
Who handles it: A Qualified Independent Contractor (QIC) -- an independent organization, not the MAC.
Deadline: 180 days from receiving the redetermination decision.
How to file: Submit a written request to the QIC identified in your redetermination notice.
Timeline: The QIC must respond within 60 days.
Level 3: Administrative Law Judge (ALJ) Hearing
Who handles it: An Administrative Law Judge at the Office of Medicare Hearings and Appeals (OMHA).
Deadline: 60 days from receiving the QIC decision.
Amount in controversy: The amount in dispute must be at least $160 (2018) to request an ALJ hearing.
How to file: Submit a written request to OMHA. You can request an in-person, telephone, or video hearing.
Timeline: ALJ hearings are currently backlogged -- expect 12-24 months for a decision.
Win rate: ALJ hearings have historically had the highest overturn rates -- approximately 40-50% of cases are decided in the beneficiary's favor.
Level 4: Medicare Appeals Council
Who handles it: The Medicare Appeals Council (part of the Departmental Appeals Board).
Deadline: 60 days from receiving the ALJ decision.
How to file: Submit a written request to the Medicare Appeals Council.
Level 5: Federal District Court
Who handles it: A federal district court.
Deadline: 60 days from receiving the Medicare Appeals Council decision.
Amount in controversy: Must be at least $1,560 (2018).
Tips for a Successful Appeal
Get your doctor involved. A letter of medical necessity from your physician is one of the most powerful tools in an appeal. The letter should explain why the service was medically necessary for your specific condition.
Submit supporting documentation. Include relevant medical records, test results, and clinical guidelines supporting the medical necessity of the service.
Be specific. Don't just say "I disagree." Explain specifically why the denial was incorrect, citing Medicare coverage rules and your medical situation.
Meet all deadlines. Missing a deadline can forfeit your right to appeal at that level.
Get help. SHINE counselors (1-800-963-5337) can help you navigate the appeals process at no cost.
Expedited Appeals for Urgent Situations
If you need an urgent decision -- for example, if you're being discharged from a hospital or SNF and believe you still need covered care -- you can request an expedited appeal. Expedited decisions must be made within 72 hours.
We do not offer every plan available in your area. Please contact Medicare.gov or 1-800-MEDICARE to get information on all of your options.
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About the Author
William Gray
Independent Medicare BrokerUS Air Force Veteran · Florida Medicare Specialist
William Gray is an independent Medicare insurance broker based in Daytona Beach and Palm Coast, FL. A US Air Force veteran (A-10 crew chief, Germany), he spent years in corporate insurance before going independent to serve Florida seniors directly. He has helped more than 1,000 clients across Northeast Florida compare Medicare Advantage, Medigap, and Part D plans — always at no cost to the client.
