Original Medicare: the five appeal levels

Original Medicare, meaning Parts A and B, has five appeal levels. Most people never need more than the first, and some win at the first. The path is the same for everyone, so this page walks through it in order. The level-by-level table is on Original Medicare (Parts A and B).

What this means

Medicare tells you its decision on a claim in a Medicare Summary Notice (MSN). It is not a bill. It must give the reasons for the decision and explain how to ask for a first appeal. The paper MSN is mailed every 6 months if you received services in that period, and an electronic notice is available monthly. Older guides say every 3 or 4 months. Because the 120-day clock runs from the notice, check your claims in your online Medicare account rather than waiting for the paper notice.

The levels, in plain words:

1. First appeal, called a redetermination. The company that pays Medicare claims in your area, the Medicare Administrative Contractor (MAC), looks again.
2. Second appeal, called a reconsideration. An outside company, the Qualified Independent Contractor (QIC), reviews the file.
3. Hearing before an Administrative Law Judge (ALJ). A judge at the Office of Medicare Hearings and Appeals (OMHA) hears your case. A minimum dollar value applies.
4. Review by the Medicare Appeals Council. The Council looks at the case fresh.
5. Federal court. A federal district court reviews it. A higher minimum dollar value applies.

What to do

1. Look at the MSN or your online account and write down the date on it (you). Count 120 days from receipt of the notice. Receipt is presumed 5 calendar days after the date on the notice.
2. Rule out a simple billing error (you and your provider). Call the provider’s billing office. A corrected claim can fix some denials without an appeal, which saves time. Do not let this delay your filing.
3. File the redetermination request (you). Use Form CMS-20027, or write to the contractor following the instructions on the MSN. There is no minimum dollar amount. The request counts as filed the day the contractor receives it.
4. Send your evidence (you and your doctor). Add a letter from your doctor. Each time you send more evidence after filing, the contractor’s decision date can move by up to 14 days.
5. If it is denied, file the reconsideration (you). Use Form CMS-20033 within 180 days of receiving the redetermination notice.
6. If you want a judge, ask in writing (you). The hearing request (Form OMHA-100) is due within 60 days of receiving the reconsideration decision. The amount still in dispute must meet the minimum, which is $200 for 2026 and stays $200 for 2027. Claims can be combined to reach it under set conditions.
7. Keep going only if the amount and the evidence justify it (you). The Council request (Form DAB-101) is due within 60 days of the judge’s decision. A court case is due within 60 days of the Council’s decision and needs at least $1,960 in dispute in 2026, rising to $2,000 for requests filed on or after 1 January 2027.

Check the date on your notice, which controls.

How long each decision should take

The contractor must send its redetermination within 60 calendar days of receiving your timely request. The QIC must send its reconsideration within 60 calendar days. If the QIC misses its deadline, you can ask in writing to move the case to a judge. The judge is to decide within 90 calendar days of receiving the hearing request, or 180 if the case was moved up from the QIC. The Council is to act within 90 days, or 180 days if moved up from the hearing office. Actual waits at the hearing level can be longer than the target. This site has not verified current waiting times.

The rule

A request for a redetermination must be filed within 120 calendar days after you receive the initial determination notice. (Title 42 of the Code of Federal Regulations (CFR), section 405.942(a))

Watch for

• “You have 60 days.” That is true at the hearing, Council and court levels. It is not true at the first level, which is 120 days.
• Late filing. A late request can be accepted for good cause. Examples in the rule include serious illness, a death or serious illness in your family, records destroyed by fire or accident, wrong information from the contractor, and not receiving the notice. Explain why in the request.
• Advance Beneficiary Notice. If a provider gave you an Advance Beneficiary Notice before the service, you may be responsible for the bill. For a denial as not reasonable and necessary, or as custodial care, Medicare may still pay when neither you nor the provider knew, or could reasonably have been expected to know, that it would not be covered. You count as knowing only if you were given written notice. Ask your State Health Insurance Assistance Program (SHIP) counselor to look at your case.
• Therapy and skilled care. Medicare coverage of skilled nursing and skilled therapy does not depend on whether you are expected to improve. Care to maintain your condition or slow decline can be covered.
• New prior authorization pilot. A test program began on 1 January 2026 in New Jersey, Ohio, Oklahoma, Texas, Arizona and Washington for selected services. This site has not verified how a non-approved request under it is appealed. Follow the notice you receive.
• Medigap. A Medicare Supplement (Medigap) insurer’s own decision is not a Medicare decision. This site has not confirmed a federal appeal for it. See Medicare Supplement (Medigap).

What next

• Medicare fast appeals cover a hospital discharge or care that is ending.
• Medicare observation status explains the new appeal right for some hospital stays.
• Find free Medicare counseling tells you how to reach a SHIP counselor, who can help you fill in the forms for free.
• Medicare, Medicare Advantage and drug plans lists every Medicare page.