Medicare Claim Denied: A Complete Guide to Appealing Your Denial

Medicare is the federal health insurance program for Americans aged 65 and older and for certain individuals with disabilities or end-stage renal disease. Medicare covers millions of people through Original Medicare (Parts A and B), Medicare Advantage (Part C), and Part D prescription drug plans. A Medicare denial is not final — Congress has built a five-level appeal system into the Medicare program that gives you multiple opportunities to have your claim reviewed.

This guide covers Medicare Original (Parts A and B) appeals. For Medicare Advantage (Part C) denials, see our separate guide on Medicare Advantage appeals.

Why Medicare Denies Claims

Medicare denies claims for both administrative and clinical reasons:

• Not medically necessary: Medicare determined the service was not required for your condition under its coverage policies
• Not a covered benefit: The service is specifically excluded from Medicare coverage
• Timely filing: The claim was submitted after the filing deadline (12 months for most providers)
• Lack of documentation: Insufficient documentation to support the medical necessity of the service
• Beneficiary not eligible: Coverage or enrollment issues at the time of service
• Duplicate claim: A claim for the same service was already processed
• Coding errors: Incorrect diagnosis or procedure codes submitted by the provider

Understanding Who Processes Medicare Claims

Medicare contracts with Medicare Administrative Contractors (MACs) to process Part A and Part B claims. There are multiple MACs, each covering different geographic regions. The MAC that processes your claim is the first point of contact for redeterminations (first-level appeals).

The Five-Level Medicare Appeal Process

Level 1: Redetermination by a Medicare Administrative Contractor (MAC)

After receiving a denial, your first appeal is a Redetermination filed with the MAC. You must file within 120 days of receiving the initial denial notice (the Medicare Summary Notice or MSN).

The MAC must decide within:

• 60 days for standard requests
• 72 hours for expedited requests involving currently receiving care

Submit your redetermination to the MAC listed on your Medicare Summary Notice. Include a written statement explaining why Medicare should cover the service, and your physician's supporting documentation.

Level 2: Reconsideration by a Qualified Independent Contractor (QIC)

If the MAC upholds the denial, escalate to a Qualified Independent Contractor (QIC) — an independent organization appointed by CMS. The QIC is entirely separate from the MAC and Medicare.

File within 180 days of the MAC redetermination decision. The QIC must decide within:

• 60 days for standard requests
• 72 hours for expedited requests

Include your full medical records, the MAC redetermination decision, and a detailed physician letter. Many denials are overturned at the QIC level when strong clinical documentation is submitted.

The current QIC for Part A and Part B appeals is C2C Innovative Solutions (c2cinnovativesolutions.com). Contact information will be on your MAC redetermination decision.

Level 3: Administrative Law Judge (ALJ) Hearing at OMHA

If the QIC upholds the denial, you can request an ALJ hearing through the Office of Medicare Hearings and Appeals (OMHA). This is a formal administrative hearing.

Requirements:

• File within 60 days of the QIC decision
• The amount in controversy must be at least $190 (adjusted annually for inflation)
• Contact OMHA at 1-855-556-8475 or omha.hhs.gov

At the ALJ hearing, you can appear in person, by phone, or by video. You can present evidence, call witnesses, and be represented by an attorney or other representative. An attorney who handles Medicare cases can significantly strengthen your position at this level.

The ALJ must issue a decision within 90 days of receiving your request.

Level 4: Medicare Appeals Council

If the ALJ rules against you, appeal to the Medicare Appeals Council (part of the Departmental Appeals Board at HHS). File within 60 days of the ALJ decision. The Medicare Appeals Council reviews the administrative record and issues a written decision. Contact: appeals.board.hhs.gov.

Level 5: Federal District Court

If the Appeals Council upholds the denial and the amount in controversy meets the federal court threshold (currently around $1,870, adjusted annually), you can file a lawsuit in federal district court. This is uncommon and usually requires legal representation.

Special Situations: Medicare Coverage Decisions

If you need Medicare to make a coverage decision before you receive care — for example, for a hospital admission, skilled nursing facility stay, or home health services — you can request a Demand Bill or ask your provider for an Advance Beneficiary Notice (ABN) to preserve your appeal rights if Medicare denies the claim.

Getting Help: Medicare Rights Center and SHIP

Medicare Rights Center: The Medicare Rights Center provides free assistance for Medicare beneficiaries with denied claims. Call their national helpline at 1-800-333-4114 or visit medicarerights.org.

State Health Insurance Assistance Program (SHIP): Every state has a SHIP that provides free, unbiased Medicare counseling. Find your local SHIP at shiphelp.org or call 1-800-MEDICARE (1-800-633-4227).

1-800-MEDICARE: Call CMS directly at 1-800-633-4227 (TTY: 1-877-486-2048) to report problems with your Medicare coverage or get help understanding your options.

Fight Back With ClaimBack

Medicare's five-level appeal system offers real opportunities to reverse a denial, but each level has strict deadlines and specific documentation requirements. ClaimBack helps you organize the right evidence and meet every deadline in the Medicare appeal process.

Start your appeal with ClaimBack

Related Reading

• How to Write an Insurance Appeal Letter
• Internal vs. External Insurance Appeals
• Common Reasons Insurance Claims Are Denied