Health & Benefits
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You have the right to file an appeal if you are found unqualified to participate in the Medicare program. You also may file an appeal if you believe that Medicare hasn't paid the proper amount for services, or if coverage has been denied for a particular service.
Filing an appeal
Your appeal rights are explained on the back of the Medicare Summary Notice (MSN). You get this notice every 4 months from the company that handles Medicare billing.
The MSN will list all the services and items that were billed to Medicare during the 4-month period and if Medicare paid for them. The last page of the MSN will also tell you why Medicare won’t pay for an item or service and how to file an appeal. If you file an appeal, ask your doctor or healthcare provider for any information that might help your case.
If you are enrolled in a Medicare Advantage Plan like an HMO or PPO, your appeal rights are explained in your plan’s materials.
There are 5 steps in Part A and Part B appeals process:
- Redetermination by the company that handles bills for Medicare,
- Reconsideration by a Qualified Independent Contractor (QIC),
- Hearing by an Administrative Law Judge (ALJ),
- Review by the Medicare Appeals Council (MAC), and
- Federal District Court Review.
Your MSN tells you if Medicare has paid your medical claim or denied it. This is the initial determination, which is made by people at the company that handles Medicare billing.
If you don’t agree with this determination, you may request a redetermination. A redetermination is when the claim is reviewed. The review decision is made by people who didn't make the initial determination.
You must file a request for redetermination within 120 days from the date you received the MSN. The request deadline date will also be listed in a box on the last page of the MSN. In most cases, the company that handles Medicare billing may send you a written decision within 60 days of getting your request.
You can request a redetermination in one of 3 ways:
- Follow the instructions on your MSN,
- Circle the items that you don’t agree with,
- Explain why you don’t agree,
- Write your name, telephone number, and Medicare number on the MSN,
- Sign,
- Keep a copy for your records, and
- Send it to the company that handles Medicare billing. The company is mentioned in the Appeal Information section of the MSN.
- Use the Medicare Redetermination Request Form and send it to the company that handles Medicare billing, or
- Send a letter to the company that handles your bills for Medicare. Your letter must include:
- Your name,
- Your Medicare number, found on your red, white, and blue Medicare card,
- An explanation of why you don’t agree with the initial determination,
- The dates of service and/or items you believe should be covered, and
- Your signature or the name and signature of your appointed representative, if you have one. You can use an Appointment of Representative form if you have one.
No matter how you ask for a redetermination, you must send it to the company that handles Medicare billing. This company is found on your MSN. You also should send any documents that you believe may help your case.
For example, you should include copies of:
- Medical bills,
- Related MSNs, and
- Information received from your doctor.
You may want to put your Medicare number on all your documents for redetermination and keep a copy for your records.
If you aren’t satisfied with the redetermination decision, called a Medicare Redetermination Notice, you may request a reconsideration.
A Qualified Independent Contractor (QIC) will make the reconsideration decision. This QIC didn’t take part in the redetermination. You must file the request for reconsideration within 180 days of the date you got the redetermination notice.
Your redetermination notice will have detailed information about how to file for reconsideration. In most cases, the QIC will send you a written review within 60 days of getting your request. If the QIC can’t issue a decision in 60 days, you may ask to skip to the next level of appeal
.
You can request a reconsideration in one of 2 ways:
- Use the Medicare Reconsideration Request Form, to the QIC, or
- Send a letter to the QIC that will handle your review.
Your letter must include the following:
- Your name,
- Your Medicare number found on your red, white, and blue Medicare card,
- The specific reason you’re asking for a reconsideration,
- The dates of service and/or items you believe should be covered,
- The name of the company that made the redetermination, which you can find on the MSN and the Medicare Redetermination Notice, and
- Your signature or the name and signature of your appointed representative, if you have one. You can get an Appointment of Representative form if you have one.
The reconsideration request should clearly explain why you don’t agree with the redetermination. Send a copy of the Medicare Redetermination Notice with your request for reconsideration to the QIC. You should also send with your reconsideration request any documents that you believe may help your case. If you send reports after the reconsideration request has been filed, it may take longer for the QIC to make a decision. Also, you may want to keep a copy of your application for your records.
If you aren’t satisfied with the QIC’s reconsideration decision, you may appeal to an ALJ through the Office of Medicare Hearings and Appeals (OMHA). You must file the request for a hearing with an ALJ within 60 days of getting the reconsideration decision.
To get a hearing, there must be a dispute that involves at least $180. In the reconsideration letter, the QIC will provide a statement of whether your case satisfies this requirement. However, it is up to the ALJ to make the final decision.
You can request an ALJ hearing in one of 2 ways:
- Fill out a “Request for Medicare Hearing by an ALJ” or written letter and mail it to OMHA addressed listed on the QIC’s reconsideration notice, or
- File an online appeal through OMHA’s website. To appeal online, you must register for an account.
If you want the ALJ to make a decision based on the information in your appeal records without having a hearing, you can also submit a Waiver of Right to an ALJ Hearing or a written letter stating that you do not wish to appear before an ALJ. This does not guarantee that there will be no hearing. If the ALJ believes a hearing is needed to decide your case, there will be a hearing.
The ALJ will generally send you a written decision within 90 days of getting your request. If the ALJ can’t issue a timely decision, you may ask the ALJ to skip to the next level of appeal.
If you need help filing an appeal with an ALJ, call (800) MEDICARE or (800) 633-4227, or call your local legal services office. TTY users should call (877) 486-2048.
If you don’t agree with the ALJ’s decision, you may file an appeal with the MAC. This appeal would be a Request for Review of ALJ Medicare Decision.
You must submit a Request for Review of ALJ Medicare Decision or written letter within 60 days of when you get the ALJ’s decision. The request can be submitted by:
- Fax to (202) 565-0227, or
- By mail to:
Department of Health and Human Services
Departmental Appeals Board Medicare Appeals Council, MS 6127
Cohen Building Room G-644 330 Independence Ave., S.W.
Washington, D.C. 20201.
The MAC will generally send you a written decision within 90 days of getting your request. If the MAC can’t issue a decision in 90 days, you may ask the MAC to skip to the next level of appeal .
Refer to the ALJ’s decision for instructions on filing a request for MAC review.
If you don’t agree with the MAC’s decision, you may file an appeal in U.S. District Court. Refer to the MAC’s decision for instructions on requesting District Court review. The claim in your appeal must:
- Involve a dispute of at least $1,840, and
- Be filed in District Court within 60 days of when you receive the MAC’s decision.
In federal court, a judge will review your case to see if the MAC fairly considered all of the evidence and properly applied the law
You are not permitted to introduce new evidence at this point, but you can submit a written argument in support of the case.
The judge can approve your claim, deny , or remand it. Remand means your case is sent back to the ALJ for another hearing that follows the judge’s instructions.
Learn more about Going to court.
Worried about doing this on your own? You may be able to get free legal help.
