120 daysFirst appeal, Original Medicare
65 daysFirst appeal, Advantage or Part D
180 daysSecond appeal, Original Medicare
60 daysHearing, Council and court
Start with your denial notice
If you have Original Medicare, the denial appears on your Medicare Summary Notice (MSN). If you have a Medicare Advantage or Part D plan, the plan sends its own denial notice. The notice gives your deadline and how to file, so read it first.
Original Medicare (Parts A and B)
| Level | Who decides | Deadline to file | Decision time |
|---|---|---|---|
| 1. Redetermination | Medicare Administrative Contractor (MAC) | 120 days from receiving the notice | Usually 60 days |
| 2. Reconsideration | Qualified Independent Contractor (QIC) | 180 days from the redetermination | Usually 60 days |
| 3. Hearing | Administrative Law Judge (ALJ) | 60 days from the reconsideration | A minimum dollar amount, set yearly, applies |
| 4. Medicare Appeals Council | Appeals Council | 60 days from the ALJ decision | |
| 5. Federal court | U.S. District Court | 60 days from the Council decision | A higher minimum amount applies |
The first two levels have no minimum dollar amount.
Medicare Advantage and Part D plans
You generally have 65 days from the date on the denial notice to ask your plan to reconsider. If the plan upholds a Medicare Advantage denial, it forwards your case to an independent review entity. Later levels (hearing, Council, court) follow the same pattern as Original Medicare.
Fast appeals
- Expedited review (72 hours): if waiting for a regular decision could seriously harm your health, ask your plan or your doctor to request a fast decision.
- Ending of hospital, nursing facility, home health, or hospice services: you can request a fast appeal with the Quality Improvement Organization (QIO) listed on your notice, generally by noon of the day after you receive it.
How to make your appeal stronger
- Ask your doctor for a letter explaining why the service or drug is medically necessary.
- Attach your MSN or denial notice, medical records, and any supporting documents.
- Keep copies and note dates. Send by a method that gives proof of delivery.
- For a drug your Part D plan will not cover, you can first request an exception with a supporting statement from your prescriber.
Missed the deadline? You can ask for an extension by explaining a good cause for filing late, such as a serious illness, or not receiving the notice. File as soon as you can.
Free help is available from your State Health Insurance Assistance Program (SHIP) at shiphelp.org and from 1-800-MEDICARE (1-800-633-4227).