Medicare Claim Denied? The Complete Guide to Appealing Parts A, B, C, and D

Medicare denies hundreds of thousands of claims every year. Whether your denial involves a hospital stay under Part A, a physician service under Part B, a drug under Part D, or a Prior Authorization Denied: How to Appeal" class="auto-link">prior authorization under your Medicare Advantage (Part C) plan, you have the right to appeal — and the law gives you up to five levels to do it. Most Medicare appeals that make it to the higher levels are won by the beneficiary.

Understanding Medicare's Five-Level Appeals Process

Federal law establishes a uniform appeals process for original Medicare (Parts A and B) and separate but parallel processes for Medicare Advantage (Part C) and Medicare Part D. Here's how the five-level process works for Parts A and B:

Level 1 — Redetermination

The first appeal is a Redetermination filed with your Medicare Administrative Contractor (MAC) — the private company that processes Medicare claims in your region. You can request a redetermination by submitting CMS Form 20027 or a written request to your MAC.

Deadline: File within 120 days of the date on your Medicare Summary Notice (MSN) or EOB)" class="auto-link">Explanation of Benefits (EOB).

The MAC assigns a different reviewer who looks at your case fresh. The MAC must respond within 60 days for Part A and B claims.

Level 2 — Reconsideration by the QIC

If the MAC upholds the denial, you can request a Reconsideration from the Qualified Independent Contractor (QIC) — a CMS-contracted entity independent from the MAC.

Deadline: File within 180 days of the MAC's redetermination decision.

The QIC reviews clinical evidence and may request additional records. It must respond within 60 days.

Level 3 — ALJ Hearing at OMHA

If the QIC upholds the denial and the amount in controversy meets the minimum threshold (currently $180 or more for 2024), you can request a hearing before an Administrative Law Judge (ALJ) at the Office of Medicare Hearings and Appeals (OMHA).

Deadline: File within 60 days of the QIC decision.

ALJ hearings are conducted in person, by video, or by telephone. You present evidence, testimony, and legal arguments. The ALJ issues a written decision. OMHA ALJ hearings reverse denials far more frequently than lower levels.

Level 4 — Medicare Appeals Council (MAC)

If the OMHA ALJ rules against you, you can appeal to the Medicare Appeals Council (MAC) within the Departmental Appeals Board (DAB).

Deadline: File within 60 days of the ALJ decision.

The MAC reviews the record for legal and factual errors. It can affirm, modify, or reverse the ALJ's decision.

Level 5 — Federal District Court

If the MAC upholds the denial and the amount in controversy meets the judicial review threshold (currently over $1,760 for 2024), you can file suit in U.S. District Court.

Deadline: File within 60 days of the MAC decision.

Medicare Advantage (Part C) Appeals

Medicare Advantage plans follow a similar but distinct process:

1. Internal appeal with the MA plan
2. Independent Review Entity (IRE) review
3. OMHA ALJ hearing
4. Medicare Appeals Council
5. Federal District Court

Deadlines are generally shorter for MA appeals. For standard appeals, the plan must respond within 30 days (7 days for pre-service expedited requests). For urgent care, request an expedited appeal — the plan must respond within 72 hours.

Medicare Part D Drug Appeals

Part D drug denials follow a parallel process:

1. Coverage determination by your plan
2. Redetermination by your plan
3. IRE reconsideration
4. ALJ hearing at OMHA
5. Medicare Appeals Council
6. Federal District Court

For Part D, you can also request a formulary exception for a drug not on your plan's formulary if your doctor certifies it's medically necessary and alternatives were inadequate.

Key Tips for All Medicare Appeals

• Get your doctor involved: A letter of medical necessity from your treating physician is the most powerful piece of evidence at every level
• Request your Medicare records: You have the right to all records used to make the denial decision
• Aid paid continuing doesn't apply to Medicare: Unlike Medicaid, Medicare does not have a general "continuation of benefits" right pending appeal — plan accordingly
• Hire a representative if the amount is significant: Patient advocates, benefits counselors, and attorneys can represent you at ALJ hearings

Fight Back With ClaimBack

Medicare's five-level appeals process is one of the most powerful consumer rights frameworks in American healthcare — but only if you use it. ClaimBack helps you draft professional appeal letters for redeterminations and QIC reconsiderations, and prepares you for the ALJ hearing with organized evidence and argument.

Start your Medicare appeal with ClaimBack

Related Reading

• What Is Medical Necessity?
• Internal vs. External Insurance Appeal: Which Should You File?
• Common Reasons Insurance Claims Are Denied