Health insurance companies don’t always pay for items the first time coverage is requested, and they don’t cover everything they’re asked to. You, the consumer, may need to file an appeal to get the coverage you believe you’re entitled to as a plan beneficiary. This is true for private health insurance, and it also sometimes happens with Medicare, the federal health insurance program designed for people age 65 and older and those with qualifying disabilities.
“There are few things more frustrating for Medicare beneficiaries on a fixed income than to find that a claim they expected to be paid was denied for coverage. No one likes a surprise medical bill,” says Bob Rees, chief sales officer with eHealth Inc., a health insurance broker and online resource provider.
Here, we’ll walk you through the Medicare appeals process, the information you’ll need to gather and times you might want to consider filing an appeal.
Common Reasons to File an Appeal
Anytime your doctor bills Medicare for a service rendered, you’ll get a statement from Medicare noting what was covered. If some or all of the claim is denied, you may need to submit an appeal to have Medicare reevaluate the decision to deny coverage.
Some common scenarios for when you might file an appeal include:
— Inappropriate claim denials: You receive a denial for a healthcare service, a piece of medical equipment or a medication that you think Medicare should cover.
— Termination of previously covered care: Medicare or your Medicare Advantage plan denies coverage for all or part of a healthcare service, item, supply or prescription drug that was previously approved or covered.
— Inadequate coverage levels: The coverage you do receive does not meet what you feel is the proper level or what your doctor indicates is medically necessary.
— Unexpected cost increases: The amount you’re being asked to pay for a healthcare service, drug or other item is now higher than you paid previously.
— Prior authorization rejections: Your plan, whether Medicare Advantage, Part D or original Medicare, depending on the state you live in, denies a request for prior authorization for a service or drug.
— Drug Management Program at-risk flags: Your use of certain prescribed medications, such as opioids and benzodiazepines, triggers the Overutilization Monitoring System, and your plan’s Drug Management Program labels you as “at-risk.” Your plan may then limit your access to coverage for those medications as a means of trying to curb abuse.
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Where to Get Free Help Filing Your Appeal
You can make a Medicare appeal yourself or seek assistance from your doctor.
“You can also appoint a representative — for example, a family member — to make the appeal on your behalf,” Rees adds.
There are two ways to appoint a representative:
1. Add a representative through your Medicare account by creating or logging into your online Medicare account and selecting “Account Settings.” From there, click on “My Representatives” and select “Manage My Representative.” Then, you’ll select “Add Representative” to add their name and address. You can edit a representative’s access whenever you want.
2. Submit an “Appointment of Representative” form, which you’ll send in with your appeal to the Medicare administrative contractor (MAC). MAC is a company that handles original Medicare claims or your Medicare Advantage health plan. That form collects important information including your and your representative’s contact details, your relationship to one another, your Medicare number, a statement explaining why you’re appointing this person and confirmation that you’re authorizing this person to send and receive identifiable health information on your behalf.
You can also seek assistance from your State Health Insurance Assistance Program. These programs are offered in every state and are staffed by highly trained counselors who will work with you one-on-one to provide unbiased help in navigating all aspects of Medicare, from the initial plan selection to filing appeals if the need arises.
[READ: Medicare Set-Aside: What It Is and How It Works]
The 5 Levels of the Medicare Appeals Process
Whether you have original Medicare or a Medicare Advantage plan, challenging a denied claim follows a five-level appeals process. The first two levels differ based on your specific coverage type, while the remaining three levels use the same administrative review bodies and monetary thresholds.
If you disagree with the response you get at any level, you can move to the next higher level. The process for doing so will be outlined in the decision letter you receive after the appeal review process for the current appeal level has been concluded.
| Appeal Level | Reviewing Body | Filing Deadline | Decision Window | 2026 Financial Threshold |
| Level 1: Redetermination or Reconsideration | Medicare administrative contractor or insurance provider | 120 days (original Medicare) or 65 days (Medicare Advantage) | 60 days (original Medicare) or 30 days (Medicare Advantage); 72 hours if expedited | No minimum dollar threshold |
| Level 2: Independent Reviewer | Qualified independent contractor or independent review entity | 180 days (original Medicare) or auto-forwarded (Medicare Advantage) | 60 days | No minimum dollar threshold |
| Level 3: Administrative Law Judge | Office of Medicare Hearings and Appeals | 60 days from Level 2 notice | 90 days | $200 minimum amount |
| Level 4: Appeals Council | Medicare Appeals Council | 60 days from Level 3 notice | 90 days | No minimum dollar threshold |
| Level 5: Judicial Review | U.S. Federal District Court | 60 days from Level 4 notice | Varies by court docket | $1,960 minimum amount |
Level 1: Redetermination or plan reconsideration
Once you’ve received a denial letter for a Medicare claim, you’ll need to start gathering information for your appeal.
— Original Medicare (redetermination): Fill out the “Redetermination Request Form” and send it to the Medicare contractor at the address listed on your MSN. This form asks for your contact information, Medicare number and claim in question, such as why you’re disputing the denial and what additional information you have to support your case. Mail all documentation to the Medicare Claims office address listed on your MSN.
— Medicare Advantage (reconsideration): Follow the instructions in your denial letter or outlined in your plan details. Your written appeal will likely need information such as your name and date of birth, the date service was rendered and the names of the items you’re appealing. You can also include additional information, such as a letter from your doctor or medical records, to help make your appeal stronger.
| Operational Stage | Original Medicare Appeals | Medicare Advantage Plan Appeals |
| Level 1 Filing Target | Medicare administrative contractor listed on Medicare Summary Notice (MSN) | Directly to your private insurance provider |
| Level 1 Submission Window | 120 days from when you receive your MSN | 65 days from when you receive notice of denial |
| Level 2 Escalation Rule | You must submit a written request to a qualified independent contractor within 180 days | Your plan automatically forwards denied claims to an independent review entity |
Most of the time, you’ll get a decision back from Medicare within 60 days of their receipt of your appeal. If your appeal is successful, Medicare will list that covered item or service on your next MSN. If your appeal is unsuccessful, you’ll get a written decision letter called a “Medicare Redetermination Notice.”
Level 2: Reconsideration by an independent review entity
If your Level 1 appeal is denied, you can move to a Level 2 appeal.
— Original Medicare: A qualified independent contractor, or QIC, won’t have participated in the Level 1 decision and will review your redetermination request and make a decision.
— Medicare Advantage: An independent review entity will perform an unbiased assessment of your request for reconsideration and make a decision.
“Relatively few appeals go beyond Level 2,” Rees notes.
Level 3: Hearing before an administrative law judge
For both original Medicare and Medicare Advantage plan beneficiaries, if you’re unsatisfied with the Level 2 determination, you can move up to Level 3 within 60 days of receiving your Level 2 notice. Level 3 appeals are decided by the Office of Medicare Hearings and Appeals, or OMHA.
To file an appeal with OMHA, your case must meet a minimum dollar amount ($200 in 2026).
This level of appeal involves a hearing before an Administrative Law Judge (ALJ). To request a hearing, follow the instructions listed on the notice you received at the conclusion of your Level 2 appeal. You can also fill out a “Request for Administrative Law Judge Hearing or Review of Dismissal” form, which details information about you, the disputed claim and why you disagree with the decision from Level 2.
During the hearing, you can present your appeal to a new, independent person who will review the facts and listen to your testimony before making a decision. This hearing is usually held by phone or video conference, but it may be held in person if the ALJ deems it necessary.
In some cases, you might be able to forego the hearing if you ask for an on-the-record review of your appeal by an ALJ or attorney adjudicator.
Level 4: Review by the Medicare Appeals Council
If you disagree with the OMHA’s decision or the OMHA doesn’t issue a timely decision, you have 60 days to move to a Level 4 appeal, which the Medicare Appeals Council makes.
You’ll receive directions in the ALJ’s hearing decision letter on how to pursue a Level 4 appeal. You can ask for this review by filling out a “Request for Review of an Administrative Law Judge Medicare Decision/Dismissal” form or submitting a written request to the Appeals Council that includes your information, the disputed claim and a statement describing what you disagree with in the ALJ’s decision and why.
There’s more information about the Appeals Council review process at HHS.gov, and you can call 1-800-MEDICARE (1-800-633-4227) for assistance with that process.
Level 5: Judicial review in federal district court
If you still disagree with the ruling from the Appeals Council, you have 60 days to request judicial review in federal district court — a Level 5 appeal. You can also seek this level if the Appeals Council doesn’t issue a timely decision.
Appeals at Level 5 are restricted by dollar amount; in 2026, the minimum dollar amount is $1,960. If you’re unable to meet this amount, you may be able to combine claims.
The Appeals Council’s decision letter will outline how to request a Level 5 appeal.
[READ: How to Use AI to Help Fight a Health Insurance Denial: Step-by-Step Guide]
Fast-Track Appeals for Immediate Healthcare Discharges
Time is of the essence when submitting an appeal, Rees notes.
“In most cases, a Level 1 appeal must be filed within 60 days of your original denial. Your insurer typically has 30 days in which to make a decision on your appeal, but you can ask for an expedited appeal of 72 hours in some cases,” he says.
The expedited appeal may apply if you’re facing an unexpected discharge from a hospital, skilled nursing facility or hospice or your services from a home health agency are ending too soon. You’ll need to:
— Ask a healthcare professional for the formal notice of denied coverage.
— Contact your local Beneficiary and Family Centered Care-Quality Improvement Organization (BFCC-QIO) by noon the day before you’re set to be discharged. The BFCC-QIO will review your medical records with an independent healthcare provider and make a decision within 72 hours.
Both original Medicare and Medicare Advantage plan beneficiaries can start this expedited appeals process at no cost.
Preventing Future Claim Denials During Annual Open Enrollment
Going through a Medicare appeals process can be confusing and frustrating. And in some cases, you may still end up on the hook to pay for what you thought should be covered. But you do have an opportunity to address that each year during the open enrollment period in the fall, when you can review and adjust your plan selections.
Use this open enrollment period strategically, End advises. Review your options and choose a plan based on your current medical conditions, prescriptions, preferred doctors and any changes you might anticipate.
While you can’t plan for every possibility, if you take the time to carefully consider your options — and work with a trusted advisor to sift through those choices — you may be able to avoid the need for future appeals.
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How to Appeal a Denied Medicare Claim: A Step-by-Step Guide originally appeared on usnews.com
Update 08/14/26: This story was published at an earlier date and has been updated with new information.
