Medicare and Medicaid — Your Appeal Rights Explained

Both Programs Have Strong Appeal Rights — Most Beneficiaries Never Use Them

Medicare and Medicaid are the two largest public health insurance programs in the United States, covering over 150 million Americans. Both programs deny claims. Both programs have formal, legal appeal processes. And most beneficiaries accept denials without ever knowing they can fight back.

Medicare Appeal Rights

Medicare provides a five-level appeal process for denied claims — from redetermination through federal court. The key facts:

• Every Medicare coverage denial is appealable
• You have 120 days from the denial to file a Level 1 redetermination
• Success rates increase at higher appeal levels — the ALJ hearing level overturns approximately 40–55% of appealed cases
• External review by a Qualified Independent Contractor is available at Level 2
• You have the right to continue receiving care in certain circumstances while an appeal is pending

Medicare covers Part A (hospital), Part B (medical), Part C(Medicare Advantage), and Part D (prescription drugs). Each part has its own appeal process with specific forms and deadlines.

Medicare Advantage — Important Differences

Medicare Advantage plans must cover everything original Medicare covers, but they manage their own prior authorization and appeals processes. Key rights:

• The plan must provide written notice of all denials with appeal rights
• You have the right to a fast appeal — within 72 hours for urgent situations
• External review is available after internal appeals
• The plan cannot deny coverage for emergency care

Medicaid Appeal Rights

Medicaid is administered by states within federal guidelines, so specifics vary — but your core appeal rights are protected by federal law.

What you can appeal:

• Denial of a service or benefit
• Reduction in services you currently receive
• Termination of services
• Failure to provide services in a timely manner
• Denial of a prior authorization request

Your Medicaid appeal rights:

• The right to a fair hearing — a formal review before a state hearing officer
• The right to continue receiving current benefits while your appeal is pending if you file within 10 days of the notice
• The right to review your case file before the hearing
• The right to be represented at your hearing
• Hearing must be scheduled within 90 days of your request in most states

The Most Important Medicaid Right — Continuation of Benefits

If Medicaid proposes to reduce or terminate a service you currently receive, and you file an appeal within 10 days of receiving the notice, your benefits must continue at the current level while your appeal is pending. This is called the continuation of benefits rule — and it is one of the most powerful rights Medicaid beneficiaries have.

How ClaimCompass Helps

ClaimCompass analyzes both Medicare and Medicaid denials and generates formally written appeal letters for every level of review.

Upload your Medicare or Medicaid denial at myclaimcompass.aifor a free analysis.

‍