Medicare Appeals — Your Four-Level Right to Appeal Explained

You Have a Legal Right to Appeal Every Medicare Denial

Medicare covers millions of Americans, and Medicare claims are denied more often than most beneficiaries realize. But every adverse coverage determination — whether a claim denial, a coverage decision, or a payment dispute — can be appealed through a formal four-level process.

Level 1 — Redetermination

The first level of Medicare appeal is a redetermination — a review by a different Medicare administrative contractor than the one who issued the original denial. You must file within 120 days of receiving the initial determination.

File by completing CMS Form-20027 or by writing a letter that includes your Medicare number, the item or service you are appealing, the date of service, and the reason you believe the denial was wrong. Submit to the address on your denial notice.

Medicare must issue a redetermination decision within 60 days.

Level 2 — Reconsideration by a Qualified Independent Contractor

If the redetermination is denied, you can request reconsideration from a Qualified Independent Contractor (QIC) — a company that is completely independent of Medicare and the contractor that denied your claim. You must file within 180 days of the redetermination notice.

The QIC must issue a decision within 60 days

Level 3 — Office of Medicare Hearings and Appeals(OMHA)

If the QIC reconsideration is denied, you can request a hearing before an Administrative Law Judge at the Office of Medicare Hearings and Appeals. This level requires that the amount in controversy meet a minimum threshold (adjusted annually — approximately $180 for 2025).

You must file within 60 days of the QIC decision. Hearings can be conducted in person, by video, or by telephone.

Level 4 — Medicare Appeals Council

If the ALJ decision is unfavorable, you can request a review by the Medicare Appeals Council — the highest administrative review level. The Council can affirm, modify, reverse, or remand the ALJ decision.

Level 5 — Federal District Court

After all administrative levels are exhausted, you have the right to file a lawsuit in federal district court if the amount in controversy meets the required threshold.

Expedited Appeals for Inpatient Hospital Care

If you are in a hospital and Medicare wants to end your inpatient coverage, you have the right to an expedited appeal through a Beneficiary and Family Centered Care Quality Improvement Organization(BFCC-QIO). This process must be initiated while you are still in the hospital.

How ClaimCompass Helps

ClaimCompass analyzes your Medicare denial and generates a complete, formally written appeal letter for your Level 1 redetermination and beyond.

Upload your Medicare denial at myclaimcompass.ai for a free analysis.