Medicare Appeals: All 5 Levels Explained

Medicare has one of the most structured and detailed appeals processes in all of health insurance. There are 5 distinct levels of appeal, each with specific deadlines, procedures, and decision-makers. The good news: Medicare's appeals process is well-defined, and beneficiaries who pursue appeals — especially to the ALJ level — win a significant percentage of the time.

Overview: The 5 Medicare Appeal Levels

Medicare Part A Appeals (Hospital, Skilled Nursing, Hospice)

Hospital Discharge Appeals

If you're in a hospital and Medicare proposes to end your inpatient stay, you have the right to an immediate appeal through your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO). The QIO can be reached at 1-888-385-4465.

Critical: If you request a QIO review before noon on the day of discharge, you can remain in the hospital at no additional cost while the QIO reviews the case. The QIO must make a decision within 1 business day. This is one of Medicare's most powerful consumer protections.

SNF, Home Health, and Hospice

If Medicare proposes to end your skilled nursing facility, home health, or hospice services, you will receive a "Notice of Medicare Non-Coverage" (NOMNC). You have until noon on the day coverage ends to file a QIO appeal. Like hospital discharge, you can continue receiving services without financial liability while the appeal is pending if filed timely.

Medicare Part B Appeals (Outpatient, Medical Services)

Part B denials (physician visits, outpatient procedures, durable medical equipment, lab tests) follow the standard 5-level process. The redetermination request should be submitted on the back of your Medicare Summary Notice (MSN) or by separate letter to the MAC listed on your MSN.

For Part B, the MAC that handles your claim is determined by your state. Contact information for all MACs is available at cms.gov/medicare/billing/medicare-contractor-provider-enrollment.

Medicare Advantage (Part C) Appeals

Medicare Advantage (MA) plans have their own internal appeals process, but must follow Medicare's guidelines. MA appeals work through the plan first, then to an Independent Review Entity (IRE), then to ALJ, MAC, and Federal Court — the same 5-level structure.

Key MA appeal deadlines:

• Pre-service (organization determination): 60 days from denial
• Expedited appeal: 72 hours from request
• Internal appeal: 60 days to file; plan must decide within 30 days
• IRE level 2: 60 days from plan's appeal decision

Medicare Part D Appeals (Prescription Drugs)

Part D prescription drug denials have a specific process under 42 CFR §423.562-423.638:

1. Coverage determination: Ask your Part D plan to cover the drug. Standard: 72 hours. Expedited: 24 hours.
2. Exception request: Request a formulary exception if the drug is non-formulary or tier exception if cost-sharing is too high. Your prescriber must support the exception.
3. Redetermination: If denied, appeal to your plan. Standard: 7 days. Expedited: 72 hours.
4. Reconsideration by IRE: 60 days to request IRE review. Standard: 7 days.
5. ALJ, MAC, Federal Court: Same as other Medicare levels.

How to File a Level 1 Medicare Redetermination

To file a Level 1 redetermination for Part B services:

1. Write "REDETERMINATION REQUEST" at the top of your letter
2. Include your Medicare ID number, claim number, date of service, and provider name
3. State specifically why you disagree with the denial
4. Attach any supporting documentation (physician letters, medical records, relevant LCD/NCD information)
5. Send to the MAC address on your Medicare Summary Notice
6. Keep a copy and note the date you mailed it

Use our Appeal Letter Generator — Scenario 18 covers Medicare Part B denial appeals.