Medicare Appeal Process: The 5 Levels, Deadlines and Fast Appeals (2026–2027)

By Vadim Marusin November 2, 2026 16 min read

You have 120 days. That is how long Original Medicare gives you to file the first appeal of a denied claim, counted from the day you get the notice, and Medicare assumes you got it 5 days after the date printed on it. Miss it without a good reason and the denial usually stands, no matter how strong your case was.

The Medicare appeal process has five levels, and most people only ever need the first one or two. But the deadlines change as you go (120 days, then 180, then 60 at every level after that), the rules differ for Original Medicare, Medicare Advantage and Part D, and there's a separate fast track measured in hours, not months, for when a hospital, nursing facility or home health agency says your Medicare coverage is ending. Here's the whole map, with the federal rule behind each step and the dollar thresholds that apply now and on January 1, 2027.

File a level 1 appeal (Original Medicare)120 daysFrom when you get the notice

Hospital discharge appealDay of dischargeCall the QIO by then

ALJ hearing minimum, 2026 and 2027$200Amount still in dispute

Federal court minimum$1,960 → $2,0002026 → filed from Jan 1, 2027

Source: 42 CFR 405.942, 405.1206; Federal Register AIC notices for CY2026 and CY2027.

Start with the Medicare Summary Notice

If you have Original Medicare, the appeal starts with a piece of mail most people skim and toss. The Medicare Summary Notice (MSN) is not a bill. It arrives every 6 months if you had services in that period, or by email for any month with a processed claim if you sign up for electronic MSNs. It lists what your providers billed, what Medicare paid, and the most you may owe, per Medicare.gov.

Two things on it matter for an appeal. Any line marked as denied, and the last page, which gives step-by-step directions and the date your appeal is due. Use that printed date. The regulation behind it (42 CFR 405.942) says 120 days from receipt, with receipt presumed 5 days after the notice date. Example: an MSN dated February 10, 2027 is presumed received February 15, 2027, so the request has to reach the contractor by June 15, 2027. "Filed" means received, not postmarked.

Before you file anything, call the provider's billing office. Medicare.gov's own advice is to check whether the office submitted the right information, because a wrong code or missing modifier can often be fixed by resubmitting the claim. That's faster than any appeal. If the provider says the claim was right and Medicare still said no, appeal.

If you're in a Medicare Advantage plan or a Part D drug plan, you won't get an MSN. Your plan sends an Explanation of Benefits and, when it denies something, a written denial notice. That notice starts your clock, and it's addressed further down.

The five levels in Original Medicare

CMS lays out the same ladder for Part A and Part B claims (CMS; Social Security Act section 1869 and 42 CFR part 405 subpart I). Each decision letter tells you how to climb to the next rung, so keep every envelope.

Original Medicare (Part A and Part B) appeal levels
Level	Who decides	You file within	Decision due	Minimum
1. Redetermination	MAC (claims contractor)	120 days	60 days	None
2. Reconsideration	QIC (independent contractor)	180 days	60 days	None
3. Hearing	OMHA judge (ALJ)	60 days	90 days	$200 (2026 and 2027)
4. Council review	Medicare Appeals Council	60 days	90 days	No new minimum
5. Judicial review	U.S. District Court	60 days	Court schedule	$1,960 (2026); $2,000 (2027)

Source: eCFR 42 CFR 405.942, 405.950, 405.962, 405.970, 405.1002, 405.1016, 405.1100, 405.1102, 405.1130; Federal Register AIC notices (2026, 2027). Filing deadlines run from the date you receive the prior decision, presumed 5 days after the date on it.

Level 1: redetermination

The Medicare Administrative Contractor (MAC) is the company that processed the claim for Medicare. You can use the Redetermination Request Form, or do it the low-tech way Medicare.gov describes: circle the denied item on a copy of the MSN, write why you disagree, add your name, phone number and Medicare Number, and mail it to the address in Step 7 on the MSN's last page. The MAC generally decides within 60 days. A win shows up on your next MSN; a loss comes as a "Medicare Redetermination Notice," which you'll need for level 2. Each time you send more evidence after filing, the MAC gets up to 14 extra days (405.950), so send what you have up front.

Level 2: reconsideration

You have 180 days from the redetermination notice. The Qualified Independent Contractor (QIC) is a separate company that didn't touch the first decision, and there's no dollar minimum (405.960, 405.962). Include a copy of the Redetermination Notice and explain specifically what the MAC got wrong. Level 2 is where your evidence needs to be complete: doctor's letters, records, the medical reason the service was needed. The QIC has 60 days. If it runs past that, you can ask to escalate the case to level 3 instead of waiting (405.970).

Level 3: a hearing with a judge

Level 3 is run by the Office of Medicare Hearings and Appeals (OMHA), and the decision comes from an Administrative Law Judge (ALJ) or an attorney adjudicator. It is the first level with a dollar floor. Today, for requests filed in 2026, the amount still in dispute must be at least $200. The CY2027 notice CMS published on September 16, 2026 keeps it at $200 for requests filed on or after January 1, 2027 (Federal Register). The hearing is usually by phone or video. If you'd rather not appear, you can ask for a decision on the written record with Form OMHA-104, and you can file the request online with OMHA, per Medicare.gov. The regulation gives the judge 90 days from when OMHA receives your request (405.1016); if that passes, you can ask to move the case to level 4.

Levels 4 and 5

The Medicare Appeals Council takes a fresh look at the judge's decision and has 90 days (405.1100). After that, federal court: you file a civil action in the district court where you live within 60 days of the Council's decision (405.1130, 405.1136). The minimum is $1,960 for cases filed in 2026 and $2,000 for cases filed from January 1, 2027. If you get this far, talk to an attorney.

Original Medicare standard appeal: days allowed at each level Calendar days, before extensions or escalation. Level 5 runs on the court's schedule.

Days you have to file
Days to decide

Source: eCFR 42 CFR 405.942, 405.950, 405.962, 405.970, 405.1002, 405.1016, 405.1100, 405.1102.

Show the numbers

	Days you have to file	Days to decide
Level 1	120	60
Level 2	180	60
Level 3	60	90
Level 4	60	90

Add up just the decision clocks for levels 1 through 4 and you get 300 days, before any time you spend filing. That's why it pays to put your full case, with every document, into levels 1 and 2 rather than saving evidence for later.

How the dollar minimum is counted

The "amount in controversy" isn't the full bill. Under 42 CFR 405.1006, it's what you were charged for the disputed items, minus anything Medicare already paid, minus the deductible and coinsurance you'd owe even if you won. Hypothetical: a provider charged $260 for a service Medicare denied, Medicare paid $0, and $30 of it would be your coinsurance anyway. The amount in controversy is $230, which clears the $200 bar for a hearing in 2026 or 2027.

Under the bar? You can combine claims. If several denials were each reconsidered by the QIC and involve similar or related services, you can ask the judge to aggregate them in one hearing request, filed within 60 days of receiving all of those reconsiderations, and Part A and Part B claims can be combined. The same annual thresholds apply to Medicare Advantage and Part D appeals; the CY2027 notice says so in its background section.

Medicare Advantage appeals

In a Medicare Advantage plan the first decision is the plan's, not Medicare's. A coverage decision is called an "organization determination," and you, your representative or your provider can ask for one before you get care. Since January 1, 2026, plans must decide standard requests for items that need prior authorization within 7 calendar days; other service requests get 14 days, and a fast request gets 72 hours (42 CFR 422.568, 422.572).

If the plan says no, the appeal is a "reconsideration." The regulation gives you 60 days from receipt of the denial, presumed 5 days after its date (422.582). Medicare.gov states the same deadline as 65 days from the date on the notice. Same thing, counted two ways.

The detail that helps you: if the plan upholds its denial in whole or in part, it has to send your case to an Independent Review Entity (IRE) under contract with CMS on its own (422.590, 422.592). You don't file level 2. And if the plan misses its decision deadline, that counts as a denial and the file goes to the IRE anyway. From level 3 on, the ladder is the same as Original Medicare: OMHA, the Council, federal court, with the same dollar minimums.

Medicare Advantage (Part C) appeal track
Step	Who decides	Your deadline	Standard decision	Fast decision
Coverage request (organization determination)	Your plan	Before or after care	7 days (prior auth) or 14 days; Part B drug 72 hours	72 hours; Part B drug 24 hours
Level 1: reconsideration	Your plan	60 days from receipt (65 from notice date)	30 days pre-service; 60 days payment; 7 days Part B drug	72 hours
Level 2: independent review	IRE under contract with CMS	Automatic if plan denies	30 / 60 / 7 days	72 hours
Level 3: hearing	OMHA judge	60 days	Same ladder as Original Medicare	Not applicable; $200 minimum in dispute
Levels 4 and 5	Council, then federal court	60 days each	Same ladder as Original Medicare	Not applicable; court minimum $1,960 (2026) / $2,000 (2027)

Source: eCFR 42 CFR 422.568, 422.572, 422.582, 422.590, 422.592, 422.602; Medicare.gov, Appeals in Medicare health plans. Plans may extend some standard timeframes by up to 14 days and must tell you in writing.

If a Medicare Advantage denial pushes you to rethink your coverage, the structural differences are in Medicare Advantage vs. Medigap in Washington. Coverage choices are a separate question from the appeal; SHIBA can help with both.

Part D drug appeals

Part D is faster at the bottom and asks more of you in the middle. A "coverage determination" (including an exception request, where your prescriber argues you need a drug the plan doesn't normally cover) must come within 72 hours, or 24 hours if expedited. For exceptions, the clock starts when the plan gets the prescriber's supporting statement (42 CFR 423.568, 423.572). Asking to be paid back for a drug you already bought takes up to 14 days and has to be in writing.

Level 1 is a "redetermination" by the plan: 60 days from receipt of the denial (65 from its date on Medicare.gov), decided in 7 days, 14 for payment, 72 hours if expedited (423.582, 423.590).

Here's the difference from Medicare Advantage: if the plan upholds its denial, level 2 is not automatic. You or your prescriber must file a written request with the Part D IRE within 60 days (423.600). Except when it misses its own deadline (or the denial is a drug-management "at-risk" decision under 42 CFR 423.590(i)), the plan does not forward it for you. Don't stop at the plan's letter assuming someone else takes it from there.

Medicare Part D appeal track
Step	Who decides	Your deadline	Standard decision	Fast decision
Coverage determination or exception	Your drug plan	Any time	72 hours (payment: 14 days)	24 hours
Level 1: redetermination	Your drug plan	60 days from receipt (65 from notice date)	7 days (payment: 14 days)	72 hours
Level 2: reconsideration	Part D IRE	60 days; you must file	7 days (payment: 14 days)	72 hours
Level 3: hearing	OMHA judge	60 days	90 days	Expedited available; $200 minimum
Levels 4 and 5	Council, then federal court	60 days each	Same ladder as Original Medicare	Not applicable; court minimum $1,960 (2026) / $2,000 (2027)

Source: eCFR 42 CFR 423.568, 423.572, 423.582, 423.590, 423.600, 423.2002; Medicare.gov, Appeals in a Medicare drug plan (steps and timeframes only; its dollar minimums are outdated). Dollar minimums: Federal Register AIC notices (2026, 2027).

For how drug coverage itself works in this state, see Medicare Part D in Washington.

Fast appeals: hospital discharge and services ending

Everything above runs in weeks and months. This part runs in hours, and the deadline is easy to miss because you're in a hospital bed when it hits.

Leaving the hospital. Within 2 days of admission you should get "An Important Message from Medicare about Your Rights." If you think you're being discharged too soon, call the number on it no later than the day you're scheduled to leave (Medicare.gov; 42 CFR 405.1206). Do that, and you can stay while the reviewer decides without paying for the extra days, other than normal coinsurance or deductibles. The hospital has to give you a detailed notice by noon the day after the reviewer contacts it, and the burden of proof is on the hospital. The reviewer decides within one day of getting the records it asked for.

Skilled nursing, home health, hospice, outpatient rehab (CORF). The provider must give you a "Notice of Medicare Non-Coverage" at least 2 days before covered services end (405.1200). Request a fast appeal by noon the day before the end date on that notice, per Medicare.gov. The reviewer must decide within 72 hours of your request under 405.1202, and coverage continues through the date on the notice while it does. The rules on skilled nursing coverage itself, including why "not improving" isn't a valid reason to stop, are in Medicare skilled nursing facility coverage.

Lost the first round? You can ask the QIC for an expedited reconsideration by noon of the day after you're told the result, and it decides within 72 hours (405.1204).

Miss a fast-appeal deadline and you can usually still get a review, but the timeframes and the protection from paying for the extra days don't apply. Call even if you're late.

Fast-track deadlines (Original Medicare)
Situation	Notice you should get	Ask for review by	Decision
Inpatient hospital discharge	Important Message from Medicare (within 2 days of admission)	The day of discharge	Within 1 day of the reviewer getting records
SNF, home health, hospice or CORF services ending	Notice of Medicare Non-Coverage (2+ days before services end)	Noon the day before the end date on the notice	Within 72 hours of your request
You disagree with the QIO's decision	QIO decision notice	Noon the day after you're told	QIC: within 72 hours
Late hospital request, already discharged	IM (already received)	Within 30 days of discharge	Within 30 days; no protection from charges

Source: Medicare.gov, Fast appeals; eCFR 42 CFR 405.1200, 405.1202, 405.1204, 405.1206.

Who you call in Washington. The reviewer is a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), a CMS contractor. For Washington it's Acentra Health; its beneficiary helpline is 1-888-305-6759 (TTY 711), per its Washington page. The number is also printed on your notice. Medicare Advantage members have the same hospital discharge right to an immediate QIO review (42 CFR 422.622). For a nursing facility or home health termination, the MA regulation sends the request to an independent reviewer under contract with CMS by noon of the day after you get the notice (422.626); use the contact on your notice.

What to put in an appeal

The regulations don't require a lawyer's brief. They do require that the right people can tell what you're appealing and why. Medicare.gov's lists for each level boil down to this:

Appeal checklist
Include	Why it matters
Name, address, Medicare Number	Lets the contractor or plan match the request to your claim
The specific item or service and date of service	Circle it on the MSN or quote the plan's denial notice
Why you think it should be covered	In plain words; tie it to the reason given in the denial
A letter or records from your doctor	Medicare.gov suggests a doctor's note to make the appeal stronger
Copy of the last decision letter	Required context at levels 2 and up (Redetermination Notice, plan denial, QIC notice)
Appointment of Representative (Form CMS-1696)	Only if someone files for you; valid one year from signing
A copy of everything, plus proof of delivery	Deadlines count from when they receive it

Source: Medicare.gov, Appeals in Original Medicare; Medicare.gov, Appeals in Medicare health plans; CMS, Original Medicare (Fee-for-service) Appeals.

Anyone can be your representative, a family member, a friend or an attorney, using Form CMS-1696 or a written notice with the elements in 42 CFR 405.910, per CMS. If you're helping a parent in a Bellevue or Spokane hospital, sign that form early. It's much harder to get the paperwork done on discharge day.

Where Washington residents get help

Two separate doors, and it pays to know which one you need.

Medicare and plan denials go through the Medicare appeal process above. For help understanding it, the Washington Office of the Insurance Commissioner points people to SHIBA, its Statewide Health Insurance Benefits Advisors. Their help is free, unbiased and confidential, and they can help you understand the denial and your appeal rights. SHIBA's line is 800-562-6900, 8:30 a.m. to 4:30 p.m., Monday through Friday (OIC). More on what they do: how SHIBA works in Washington.

Medigap disputes are different. A Medicare Supplement policy is regulated by the state, not by Medicare. If your Medigap insurer won't pay its share of a claim Medicare already approved, the OIC says to file a complaint with the OIC rather than a Medicare appeal. Background on the policies themselves: Medicare Supplement insurance in Washington.

My read after going through all of these rules side by side: the process rewards the basics. File by the date printed on the notice, get a letter from your doctor, and take it to the second level instead of stopping at the first "no." For an overview of coverage options here, see Medicare in Washington.

Questions

What are the 5 levels of Medicare appeals?

Redetermination by the Medicare Administrative Contractor, reconsideration by a Qualified Independent Contractor, a hearing with an Administrative Law Judge at OMHA, review by the Medicare Appeals Council, and judicial review in federal district court.

How long do I have to file a Medicare appeal?

In Original Medicare, 120 days from receiving the Medicare Summary Notice for level 1 and 180 days for level 2; 60 days at each later level. Medicare Advantage and Part D give 60 days from receipt of the plan's denial, which Medicare.gov states as 65 days from the date on the notice.

What is the minimum amount for a Medicare ALJ hearing?

$200 for requests filed in 2026, and $200 for requests filed on or after January 1, 2027. Federal court requires $1,960 in 2026 and $2,000 from January 1, 2027. You may be able to combine claims to reach the minimum.

How do I appeal a hospital discharge under Medicare?

Call the BFCC-QIO listed on your Important Message from Medicare no later than the day you are scheduled to be discharged. In Washington that is Acentra Health, 1-888-305-6759. If you ask on time, you can stay while the QIO decides without paying for the extra days, other than normal coinsurance or deductibles.

Your own plan documents and federal Medicare rules control your situation. Deadlines are printed on each notice; follow them. Confirm the details with SHIBA, 1-800-MEDICARE, a licensed agent, or (for legal questions) an attorney.

Sources

This article is for general educational purposes only and is not legal, tax or insurance advice. Coverage depends on the actual policy, its terms, conditions and exclusions, and state law. Maru Insurance · WA License (WAOIC) #1365574 · FL License #G363233 · NPN 22261820.