Appeals in Original Medicare

Level 1 appeals : Redetermination

The first level of appeal in Original Medicare is called a Redetermination.

Start your appeal by looking at your "Medicare Summary Notice(MSN). You must file your appeal by the date in the MSN. If you miss the deadline for appealing, you may still file an appeal and get a decision if you can show good cause for missing the deadline (for example, if you have a disability, illness, or accident that delayed you from sending it by the deadline). What’s considered good cause for missing the deadline?

Next, decide how to file your appeal:

1. Fill out a "Redetermination Request Form [PDF, 100 KB]" and send it to the Medicare Administrator Contractor. Where can I find the address to the MAC office?
2. Follow the appeal instructions in your MSN:
   • Circle the item or service you wish to appeal on a copy of your MSN.
   • Explain in writing on your MSN or a separate piece of paper why you disagree with the initial determination.
   • Include your name, number, and Medicare Number on your MSN.
   • Include any other information you have about your appeal. You can ask your provider for information that may help your case.
   • Mail your documentation to the Medicare Claims office address listed in Step 7 on the last page of your MSN.
   • Submit a written request to the Medicare Administrator Contractor (MAC). The company’s address is listed on the last page of your MSN. Where can I find the address to the MAC office?
      
     Your appeal must include:
     • Your name, address, and the Medicare Number on your Medicare card [JPG].
     • List the specific items and/or services and dates you’re filing an appeal about. You can also circle the items and/or services you wish to appeal on a copy of your MSN.
     • Why you think the items and/or services should be covered.
     • If you've appointed a representative, a copy of the "Appointment of Representative" form [PDF, 47.7 KB] or any written instrument that has the required elements.
     • Any other information that may help your case (like a doctor’s note).

You’ll generally get a decision from the Medicare Administrative Contractor (MAC) within 60 days after they get your appeal. If the MAC decides that Medicare will cover the appealed item(s) or service(s), it will be listed on your next MSN. If the MAC decides that Medicare won’t cover the appealed item(s) or service(s), you’ll get a written decision letter (called a “Medicare Redetermination Notice”).

If you disagree with the MAC's decision:

You have 180 days after you get the MAC’s decision letter or an MSN to ask for a level 2 appeal, called a “Reconsideration” by a Qualified Independent Contractor (QIC).

Level 2 appeals: Qualified Independent Contractor (QIC) Reconsideration

A QIC is an independent contractor that didn’t take part in the level 1 decision. The QIC will review your request for a reconsideration and make a decision. Your request should clearly explain why you disagree with the redetermination decision from level 1. It’s helpful to send a copy of the “Medicare Redetermination Notice” with your request for a reconsideration to the (QIC).

Next, decide how to file your reconsideration:

1. Fill out a Medicare Reconsideration Request Form and send it to the QIC listed on your Medicare Redetermination Notice (MRN), or
2. Submit a written request to the QIC that includes:
   • Your name, address, and the Medicare Number on your Medicare card [JPG].
   • List the specific items and/or services and dates you’re filing a reconsideration about. You can also circle the items and/or services you wish to reconsider on a copy of your MSN.
   • An explanation of why you disagrees with the redetermination, and any evidence that might help make your appeal stronger.
   •  A copy of the MRN or RA, and any other relevant documentation
   • Name of the party or the authorized or appointed representative of the party
   • Name of the contractor that made the redetermination
   • Any missing documentation identified in the notice of redetermination

The QIC will send you a decision within 60 days after the QIC gets your appeal request.

If you’re dissatisfied with the QIC’s decision, you have 60 days from the date of the QIC’s decision to ask for a level 3 appeal.

Level 3 appeals: Decision by the Office of Medicare Hearings and Appeals (OMHA)

If you file an appeal with OMHA the amount of your case must meet a minimum dollar amount. For 2024, the minimum dollar amount is $180 ($190 in 2025).

You can ask for a hearing before an Administrative Law Judge (ALJ) or, in certain circumstances, if you don’t wish to have a hearing, you can ask for an on the record review of your appeal by an ALJ or attorney adjudicator. To ask for a hearing before an ALJ, follow the directions on the "Medicare Reconsideration Notice" you got from the Qualified Independent Contractor (QIC) in your level 2 appeal.

A hearing before an ALJ allows you to present your appeal to a new person who will independently review the facts of your appeal and listen to your testimony before making a decision. An ALJ hearing is usually held by phone or video-teleconference, but can also be held in person if the ALJ finds that you have a good reason.

You or your representative can ask for a hearing in one of these ways:

• Fill out a "Request for Medicare Hearing by an Administrative Law Judge" form [PDF, 96.6 KB].
• Submit a written request, which must include:
  • Your name, address, phone number, and Medicare Number. If you've appointed a representative, include the name, address, and phone number of your representative.
  • The appeal number assigned by the QIC if any.
  • The dates of service for the items or services you're appealing.
  • Why you disagree with the QIC's decision.
  • Any information to make your appeal stronger. If you can't include this information with your request, include a statement explaining what you plan to submit and when you'll submit it.
• File an appeal online with OMHA.

Get more information about the ALJ hearing process or call us at 1-800-MEDICARE (1-800-633-4227).

How do I ask for a review of my case without a hearing?

You can ask OMHA to make a decision without holding a hearing (based only on the information that's in your appeal record). The ALJ or attorney adjudicator may also issue a decision without holding a hearing if the appeal record supports a decision that's fully in your favor.

To ask OMHA to make a decision without a hearing (based on only the information that's in your appeal record), submit the information required for an ALJ hearing (listed above) and one of these:

• The "Waiver of Right to an Administrative Law Judge (ALJ) Hearing" form (Form OMHA-104).
• A written request stating that you don't wish to appear before an ALJ at a hearing (including a hearing held by phone or video-teleconference).

Even if you waive the ALJ hearing, a hearing may still be held by an ALJ if the other parties in your case who were sent a notice of hearing (for example, your provider) don’t also waive the ALJ hearing, or if the ALJ believes a hearing is necessary to decide your case.

If you asked OMHA for a decision without a hearing, but the ALJ decides a hearing is necessary, the ALJ will let you know when the hearing will be. If no hearing is held, either an ALJ or attorney adjudicator will review the information in your appeal record and make a decision.

You can ask to move to appeals level 4 if:

• OMHA doesn't issue a timely decision.
• You disagree with the OMHA's decision.

You have 60 days after you get the decision to move to appeals level 4, by asking for a review by the Medicare Appeals Council (Appeals Council).

Level 4 appeals: Review by the Medicare Appeals Council

To ask for a level 4 appeal, follow the directions in the ALJ's hearing decision you got in the level 3 appeal.

You can ask for the Medicare Appeals Council (Appeals Council) review in 1 of 2 ways:

• Fill out a "Request for Review of an Administrative Law Judge (ALJ) Medicare Decision/Dismissal" form [PDF, 30.5 KB].
• Submit a written request to the Appeals Council that includes:
  • Your name and Medicare Number. If you've appointed a representative, include the name of your representative. How do I appoint a representative?
  • The specific item(s) and/or service(s) and specific date(s) of service you're appealing.
  • A statement describing what you disagree with in the ALJ's decision and why.
  • The date of the ALJ decision.
  • If you're asking that your case be moved from the ALJ to the Appeals Council because the ALJ hasn't issued a timely decision, send your ask to the OMHA address listed on the QIC's reconsideration notice (or if you know that your case was assigned to an OMHA adjudicator, to the hearing office where it’s pending).

For more information about the Appeals Council review process, visit HHS.gov, or call us at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

You can request judicial review in Federal district court (level 5) if:

• The Appeals Council doesn't issue a timely decision:
• You disagree with the Appeals Council's decision in level 4.
• The amount of your case meets a minimum dollar amount. For 2024, the minimum dollar amount is $1,840. You may be able to combine claims to meet this dollar amount.

You have 60 days after you get the Appeals Council’s decision to ask for judicial review by a federal district court.

Level 5 appeals: Judicial Review in Federal district court

To get a judicial review in Federal district court, the amount of your case must meet a minimum dollar amount. For 2024, the minimum dollar amount is $1,840. You may be able to combine claims to meet this dollar amount.

Follow the directions in the Appeals Council’s decision letter you got in your level 4 appeal to file for judicial review in federal court.

Coming soon: Appeal when a hospital changes your status from "inpatient" to "outpatient with observation services"

As a result of a court order, you have appeal rights when a hospital changes your status from “inpatient” to “outpatient” if you also meet certain criteria.

Starting January 1, 2025, you can ask for an appeal if you were admitted to the hospital as an inpatient on or after January 1, 2009, and your status was changed to “outpatient getting observation services” (and you meet certain other criteria). Learn how to file this type of appeal.

Starting February 14, 2025, you can ask for a fast appeal while you’re still in the hospital if you were admitted to the hospital as an inpatient and the hospital changed your status to “outpatient getting observation services.” More information on how to file this type of appeal will be available soon.

Why does hospital status matter?

Your hospital status affects how much you pay for hospital services. Your hospital status may also affect whether Medicare will cover care you get in a skilled nursing facility (SNF) after your hospital stay.