How to appeal a Medicare denial: the 5 levels, deadlines and fast appeals

Sooner or later most people on Medicare get a notice saying something was not covered, or a plan says no to a test, a drug or a few more days in a facility. Many people stop there and pay the bill. They don't have to. Every person with Medicare has the right to ask for a review of a coverage or payment decision, and the process is written down in detail by the government, with deadlines on both sides.

This guide walks through that process the way the Centers for Medicare & Medicaid Services (CMS) lays it out in its booklet Medicare Appeals (April 2026) and in Section 8 of the Medicare & You 2027 handbook: what you can appeal, the five levels for Original Medicare, Medicare Advantage and drug plans, the fast appeal when a hospital or facility says your care is ending, and the notices that tell you where you stand. The dollar minimums shown are the 2026 amounts printed in the booklet.

What you can appeal

An appeal is the action you take when you disagree with a coverage or payment decision by Medicare or your Medicare plan. CMS says you can file an appeal if Medicare or your plan refuses to:

• Cover a health care service, supply, item or drug you think should be covered.
• Pay for a health care service, supply, item or drug you already got.
• Change the amount you must pay for a health care service, supply, item or drug.
• Provide or pay for all or part of a service, supply, item or drug you think you still need.
• Cover drugs like opioids and benzodiazepines because a Part D drug management program labeled you "at-risk."

The handbook adds two more situations: a claim denied because of an open accident record when the claim is not related to the accident, and, in Original Medicare, a hospital changing your status from inpatient to outpatient getting observation services. That last one matters a great deal, and it has its own section below.

Before you start, CMS's advice is the same everywhere in the booklet: ask your doctor, other provider or supplier for any information that will make your appeal stronger, and keep a copy of everything you send.

Appeals and complaints are different things

An appeal is about whether something is covered or paid. A complaint, which Medicare also calls a grievance, is about the way a plan or provider is treating you. If your plan refuses to cover a service, supply or prescription, that is an appeal. If you cannot get through to the plan's customer service, a staff member was rude, you wait too long for a prescription, or the plan sends you materials you did not ask for, that is a grievance.

Some grievances are about the appeal process itself. CMS lists examples such as a plan that did not decide a reconsideration on time, did not send your case to the independent reviewer, refused your request for a fast appeal, or did not give you the notices it was required to give. Concerns about the quality of care you got can go to your plan and to your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), an independent group of doctors and health experts under contract with Medicare.

For drug plans, the booklet gives specific grievance rules. You must file within 60 days of the event that led to the complaint, by phone or in writing. The plan generally must tell you its decision no later than 30 days after it gets the complaint, a timeframe that can be extended by up to 14 days. If the complaint is about the plan refusing to make a fast decision and you have not bought or gotten the drug, the plan must answer within 24 hours. If the plan does not address your complaint, call 1-800-MEDICARE.

Getting someone to help you

You do not have to handle an appeal alone. You can appoint a representative, such as a family member, friend, advocate, attorney, doctor or someone else, in one of two ways:

• Fill out the "Appointment of Representative" form (CMS-1696) and send it with your appeal.
• Send a written request that includes your name, address, phone number and Medicare Number; a statement appointing the person; their name, address and phone number; their professional status or relationship to you; a statement authorizing release of your health information to them; and a statement explaining why you are being represented and to what extent.

In some cases your doctor can act without being appointed. In a Medicare Advantage Plan, your treating doctor can ask for an organization determination or certain pre-service reconsiderations on your behalf. In a drug plan, your doctor or other prescriber can ask for a coverage determination, a redetermination or a reconsideration by the independent reviewer. For higher levels, you need the form or the written request.

Free help is also available from your State Health Insurance Assistance Program (SHIP), which gives personalized counseling, including help with appeals. You can find yours at shiphelp.org or by calling 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048).

Appeals in Original Medicare

If you have Original Medicare, everything starts with the Medicare Summary Notice (MSN). You get one in the mail at least every 6 months if you had covered services, or by email for any month you have a processed claim if you sign up for electronic notices in your Medicare.gov account. The MSN shows everything providers billed to Medicare in the period, what Medicare paid, what you may owe, and whether each claim was approved or fully or partly denied. That decision is the initial determination, made by the Medicare Administrative Contractor (MAC), the company that processes Medicare claims.

Read every MSN. If an item you expected is missing, keep in mind that your provider has up to one year from the date of service to submit a claim, and you can ask the provider for an itemized statement of what it billed.

There are 5 levels of appeal in Original Medicare:

Level 1: redetermination by the MAC

You must file by the date listed on your MSN. If you miss it, you may still get a decision if you can show good cause, such as a disability, illness or accident that kept you from filing in time. There are three ways to file:

• Circle the items you disagree with on a copy of the MSN, explain in writing why you disagree (on the MSN or a separate sheet), add your name, phone number and Medicare Number, and mail it to the Medicare Claims office address in Step 7 on the last page of the MSN.
• Fill out the "Medicare Redetermination Request" form (CMS-20027) and mail it to the same address.
• Send a written request to the MAC with your name and Medicare Number, the specific items and dates of service, why you think they should be covered, a copy of any representative appointment, and anything else that helps your case.

Write your Medicare Number on every document you send. The people at the MAC who decide your appeal are separate from the people who made the original decision. You will generally get a decision, in a letter or on your next MSN, within 60 days after the MAC gets your appeal. You can send more evidence after you file, but the MAC gets an extra 14 calendar days each time you do.

Level 2: reconsideration by a QIC

If you disagree with the MAC, you have 180 days after you get its decision letter or MSN to ask for a reconsideration by a QIC, an independent contractor that did not take part in the first decision. Follow the directions on the "Medicare Redetermination Notice" and send your request to the QIC address listed there, either on the "Medicare Reconsideration Request" form (CMS-20033), which comes with the notice, or in a written request that names the items, the dates of service, the MAC that decided, and why you disagree.

Everything you sent at Level 1 goes to the QIC automatically. In most cases the QIC sends a written decision about 60 days after it gets your request. If it cannot finish in 60 days, you may ask to move your case to the next level, and the QIC will send a notice explaining your options.

Level 3: a hearing before an administrative law judge

If you disagree with the QIC, you have 60 days after you get its decision to ask OMHA for a hearing before an administrative law judge (ALJ). The hearing lets you present your case to a new person who reviews the facts independently and listens to your testimony. It is usually held by phone or video teleconference, and can be held in person if the ALJ finds you have a good reason.

To reach this level, the amount in dispute must meet a minimum. For 2026, the minimum is $200, and you may be able to combine claims to meet it. The QIC's decision letter may say whether your case is estimated to meet the minimum, but the ALJ decides.

You can ask on the "Request for Administrative Law Judge Hearing or Review of Dismissal" form (OMHA-100), which comes with the QIC decision, or in a written request. You can also ask OMHA to decide based only on the record, without a hearing, using form OMHA-104 or a written request; a hearing may still be held if other parties, such as your provider, do not also waive it, or if the ALJ believes one is needed.

Level 4: the Medicare Appeals Council

If you disagree with OMHA's decision, you have 60 days after you get it to ask the Medicare Appeals Council for a review, regardless of the dollar amount. You can use form DAB-101 or a written request that names the items and dates of service, identifies the parts of the decision you disagree with and why, and gives the date of the OMHA decision. Send a copy of your request to your provider.

Level 5: federal district court

You can ask for judicial review in federal district court if you disagree with the Appeals Council's decision, or if the Council does not decide on time, and the amount of your case meets a minimum. For 2026, that minimum is $1,960, and you may be able to combine claims to meet it. You have 60 days after you get the Council's decision or notice to file, following the directions in its letter.

Appeals in a Medicare Advantage Plan

A Medicare Advantage Plan must tell you in writing how to appeal, and its contact information is generally on your membership card. The process starts with an organization determination: the plan's decision on whether it will provide or pay for an item, service or Part B drug. You, your representative or your provider can ask for one in advance to make sure something is covered. The plan must decide an advance request within:

• 72 hours for Part B drugs.
• 7 days for items and services that require prior authorization.
• 14 days for all other items and services.

If waiting could seriously harm your health, ask for a fast decision. When the plan agrees, or your doctor tells the plan that waiting could seriously jeopardize your life, health or ability to regain maximum function, it must decide within 24 hours for Part B drugs or 72 hours for items and services. If you already got the care and are asking the plan to pay, it must process the request within 60 days. Some timeframes can be extended by up to 14 days, and the plan must tell you in writing if it takes an extension.

If the plan says no, you get a notice explaining why and how to ask for a reconsideration. You or your representative must file that Level 1 appeal within 65 days from the date on the plan's denial notice. Include your name, address and Medicare Number, the items or services and dates, your reasons, proof of representation if you have a representative, and anything that strengthens your case, like a doctor's note. If the appeal is for a service you have not gotten yet, your doctor can ask for the reconsideration for you.

Here is how long the plan (Level 1) and the Independent Review Entity (Level 2) have to decide:

One feature is easy to miss: if the plan decides against you, fully or partly, your appeal goes to Level 2 automatically. You do not have to file anything to get the Independent Review Entity (IRE) to look at it. From there, the path matches Original Medicare: 60 days after the IRE decision to ask OMHA for a hearing ($200 minimum in 2026), 60 days after that to ask the Appeals Council (any amount), and 60 days after the Council's decision to go to federal district court ($1,960 minimum in 2026). An OMHA appeal can also be filed online through OMHA's electronic portal.

If you have a Medicare Cost Plan and are appealing services you got outside its network, you follow the Original Medicare process instead. If you are in PACE, the PACE organization gives you its own written appeal rights.

Appeals for Part D drug coverage

Drug coverage has its own steps, whether it comes through a stand-alone drug plan or a Medicare Advantage Plan with drug coverage. When a pharmacist tells you your plan will not cover a drug, or will cover it at a higher cost than you think you should pay, the pharmacist should give you a notice explaining how to contact the plan. If you don't get one, ask for it.

Your first options are to talk to your prescriber, who can check whether you meet prior authorization or step therapy requirements or suggest a less expensive drug that works as well, and to ask the plan for a coverage determination. That is the plan's first decision about your drug: whether it covers it, whether you meet its rules, or how much you pay. You can also ask for an exception if:

• The drug is not on the plan's formulary and the other options on it will not work for you.
• Your prescriber believes you cannot meet a coverage rule, such as prior authorization, step therapy, or quantity or dosage limits.
• You think the plan should charge less for a non-preferred tier drug because the preferred tier options will not work for you.

An exception needs a supporting statement from your prescriber explaining the medical reason, and the plan's clock starts when it gets that statement. A standard coverage determination must be decided within 72 hours, a fast one within 24 hours, and a request to be paid back for a drug you already bought within 14 calendar days. You cannot get a fast decision if you already paid for and got the drug.

If the plan still says no, the drug appeal levels are:

At Levels 1 and 2, the plan and then the IRE must decide a fast appeal as quickly as your health requires but no later than 72 hours, a standard appeal about a drug you have not gotten in 7 days, and a request to be paid back in 14 days. At Levels 3 and 4 the standard timeframe is 90 days; a fast decision is generally made no later than 10 days after OMHA or the Council gets your request. For Level 5, check with the clerk's office of the federal district court for how to file.

Unlike Medicare Advantage medical appeals, a denied drug redetermination does not move up on its own, so you or your prescriber must ask the IRE, which may also call itself the "Part D QIC," using the form the plan sends with an unfavorable decision. The one exception is an appeal of a drug management program limitation: if the plan denies it, the appeal goes to the IRE automatically and you get a written notice. Standard redetermination requests must be in writing unless the plan allows phone requests. For what drug coverage itself costs, see our Part D costs page and the Part D 2027 guide.

The fast appeal when care is ending too soon

This is the appeal that matters most in a crisis. If you think your Medicare-covered services are ending too soon, or you are being discharged too soon, from a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility or hospice, you can ask for a fast appeal (also called an immediate or expedited appeal). An independent reviewer, the BFCC-QIO for your state, decides whether your covered services should continue. The notice you get lists how to contact it.

In a hospital

Within 2 days of your admission and before your discharge, the hospital should give you a notice called "An Important Message from Medicare about Your Rights," often called the IM. It explains your right to all medically necessary hospital services, to be involved in decisions about your care, to get services you need after you leave, and to appeal a discharge decision. If the hospital gave you the IM more than 2 days before your discharge day, it must give you a copy of the signed original or a new one before you leave. If you don't get the notice, ask for it.

To use the fast appeal, follow the directions on the IM no later than the day you are scheduled to be discharged. If you ask in time, you can stay in the hospital while you wait for the decision, and you will not have to pay for that stay except for any applicable coinsurance or deductibles. After the BFCC-QIO notifies the hospital, the hospital must give you a "Detailed Notice of Discharge" by noon the next day explaining why it believes your services should end. The BFCC-QIO decides within one day of getting the information it needs.

• If the reviewer agrees your services are ending too soon, Medicare keeps covering your hospital stay (except coinsurance or deductibles) for as long as it is medically necessary.
• If the reviewer decides your services should end and you met the deadline, you are not responsible for hospital charges (except coinsurance or deductibles) through noon of the day after you get the decision. Inpatient services after that may be your cost.

If you miss the deadline, you can still ask the BFCC-QIO to review your case, but different rules apply, and you might be responsible for the cost of the stay past the day the hospital first tried to discharge you.

In a skilled nursing facility, home health, rehabilitation facility or hospice

In these settings you should get a "Notice of Medicare Non-Coverage" at least 2 days before covered services end. Follow its instructions no later than noon the day before the termination date on the notice. The provider must then give you a "Detailed Explanation of Non-Coverage" by the end of the day it hears from the BFCC-QIO, and the reviewer decides by close of business the day after it gets the information it needs. If the reviewer agrees with you, Medicare may continue to cover your care depending on your needs. If not, you are not responsible for services provided before the coverage end date on the notice, but you may have to pay for services after it.

The handbook gives a specific example worth knowing: if you are discharged from skilled care only because you are not improving, but you still need skilled care to keep your condition from getting worse, you can appeal. A fast appeal generally covers only the decision to end services; if items or services are denied afterward, you may need a regular claim appeal. Our guide to what Medicare doesn't cover explains the skilled nursing and home health rules behind these decisions.

When the hospital changes you from inpatient to observation

If you have Original Medicare, were formally admitted as an inpatient, and the hospital later changed your status to outpatient getting observation services, you have the right to a fast appeal while you are still in the hospital. You should get a "Medicare Change of Status Notice" (CMS-10868) before you leave. It explains that:

• Your stay will be billed to Part B instead of Part A, so your bill may be lower or higher than the Part A inpatient deductible.
• If you don't have Part B, the hospital will charge you the full cost of your outpatient stay.
• Medicare will not pay if you go to a skilled nursing facility after you leave the hospital.
• How to contact your state's BFCC-QIO to ask for a fast appeal.

The BFCC-QIO asks the hospital for your records, lets it explain the change, and tells you its decision about 2 days after you file. If it decides your status should not have changed, you pay the Part A inpatient deductible and may qualify for a Medicare-covered skilled nursing facility stay within 30 days of your discharge, if you meet the other requirements. If it decides the change was right, you pay the Part B costs and will not qualify for a covered skilled nursing stay. The dollar side of that difference is on our Part A costs page.

The notices that tell you something may not be covered

Advance Beneficiary Notice of Non-coverage (ABN, form CMS-R-131). If you have Original Medicare and your doctor, provider or supplier thinks Medicare probably will not pay for an item or service, they may give you an ABN listing the items, an estimate of the cost and the reasons. You must pick one of three options and sign:

• Option 1: you want the item or service and want a claim sent to Medicare. You may be asked to pay now; if Medicare denies the claim you are responsible, but you can appeal. If Medicare pays, you get a refund minus your copayments and deductibles.
• Option 2: you want it but do not want a claim sent to Medicare. You pay, and you cannot appeal.
• Option 3: you do not want it. You do not pay, no claim is sent, and you cannot appeal.

An ABN is not an official denial by Medicare. If you choose Option 1 and Medicare denies payment, you can still appeal once the MSN arrives. And the handbook adds a protection many people never hear about: if your provider was required to give you an ABN but did not, in most cases the provider must refund what you paid. Providers do not have to give an ABN for services Medicare never covers, such as dental services, hearing aids, routine eye exams and routine foot care.

Other notices you may see:

• Skilled Nursing Facility ABN (CMS-10055), when the facility believes Medicare may not cover or continue to cover your stay. You do not pay for Part A services until a claim is filed and officially denied, though you keep paying your usual costs, such as the daily coinsurance.
• Hospital Issued Notice of Non-coverage (HINN), when Medicare may not cover all or part of your inpatient care. There are 4 types: preadmission/admission, hospital requested review, noncovered services during a covered stay, and noncovered continued stay.
• Home Health Change of Care Notice, when your home health agency reduces or stops some services, and the Notice of Medicare Non-Coverage when all covered home health services are ending.

In a Medicare Advantage Plan, you can protect yourself before you get care by asking the plan in advance whether it covers a service, drug or supply, through a pre-service request for an organization determination. If the plan denies it, the response tells you how to appeal.

If your plan leaves Medicare

Medicare health and drug plans can decide not to participate in Medicare for the coming year. When that happens, your coverage under the plan ends after December 31, and the plan sends you a letter explaining your options:

• You can choose another plan from October 15 to December 7, with coverage starting January 1.
• You have a special right under federal law to join another Medicare health plan until the last day in February.
• You may have the right to buy certain Medigap policies within 63 days after your plan coverage ends.

Our open enrollment page covers the regular sign-up windows, and the Original Medicare vs Medicare Advantage guide explains how Medigap fits in.

Your other rights, and protecting your records

The handbook lists the rights every person with Medicare has. Among them: to be treated with courtesy, dignity and respect; to be protected from unlawful discrimination; to have your personal and health information kept private; to get information in a way or language you understand, including braille or large print; to learn about treatment choices in clear language and take part in decisions; to get Medicare-covered services in an emergency; and to get a decision about payment or coverage, with a notice saying what will and won't be covered.

You also generally have the right to see and get copies of your health information from the providers and plans that treat you and pay for your care, including claims and billing records, enrollment records and medical records. It may take up to 30 days to get a response. You may have to pay a fee, which typically cannot be more than the cost of labor, supplies and postage, and in most cases there is no charge for getting your information through an electronic portal. Those records are often the evidence that wins an appeal.

Watching for billing errors and fraud

Appeals and fraud protection start in the same place: your statements. CMS suggests recording the dates you get care on a calendar and saving receipts and statements so you can check them. If you have Original Medicare, your claims are generally available in your Medicare.gov account within 24 hours after processing, and you can download your claims data there. If you know the provider, you can ask for an itemized statement, which they should give you within 30 days.

If you suspect Medicare was billed for something you did not get, or you do not recognize the provider, call 1-800-MEDICARE. Only give your Medicare Number to doctors and other Medicare providers, insurance companies and their licensed agents, your plan, or state programs that work with Medicare. Medicare or a plan representative will call you only in limited situations: your own plan or the agent who helped you join it, a 1-800-MEDICARE representative returning your message, or a follow-up on a fraud report you filed.

A short checklist

• Read every MSN or plan statement, and note the appeal deadline printed on it.
• Ask your doctor or supplier for records and a letter supporting your case.
• Keep copies of everything you send, and send it to the exact address on the notice.
• In a hospital or facility, read the IM or the Notice of Medicare Non-Coverage the day you get it, and call the BFCC-QIO before the deadline.
• On an ABN, know that Option 2 and Option 3 give up your right to appeal.
• Call your SHIP for free help, or appoint a representative.

More information is at Medicare.gov/appeals, and appeal forms are at Medicare.gov/basics/forms-publications-mailings/forms/appeals. If you have other insurance alongside Medicare, our who pays first checker helps you see which insurer should get the claim, and military retirees can read the TRICARE For Life guide.