Official Medicare Publications & Guides

Medicare Appeals: Your Right to Fight a Coverage Denial

Medicare has a formal five-level appeals process for denied or reduced coverage. This guide explains how to challenge decisions under Original Medicare, Medicare Advantage, and Part D drug plans, including fast appeals and your right to appoint a representative.

Feb 28, 2023 · 5 min read

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Who Should Read This

This publication is essential reading for anyone enrolled in Medicare who has ever received a denial, a reduced payment, or a notice that coverage for a service is ending. That includes people with Original Medicare (Parts A and B), those enrolled in a Medicare Advantage Plan or other Medicare health plan, and anyone who has Medicare drug coverage through Part D. If you are a family member, caregiver, or friend helping someone navigate a Medicare coverage dispute, this guide is for you as well. Anyone approaching Medicare eligibility who wants to understand their rights before they need them will also benefit from reading this material.

Quick Overview

The CMS publication 'Medicare Appeals' explains your legal right to challenge any Medicare coverage or payment decision you disagree with, and walks you through the step-by-step process for doing so. It covers how to appeal under Original Medicare, Medicare Advantage plans, and Medicare drug plans, as well as how to get help filing and how to appoint someone to represent you. The booklet is 58 pages and is written in straightforward language intended for people with Medicare and their families.

Key Takeaways

You have the right to appeal any Medicare decision that denies, reduces, or stops coverage for a health care service, supply, or prescription drug you believe you need.
There are five levels of appeal. If you lose at one level, you can generally move to the next, all the way up to a Federal District Court.
Deadlines matter. You typically have 120 days from receiving your Medicare Summary Notice to file a Level 1 appeal under Original Medicare, and 60 days to move between most higher levels.
You can appoint a representative — a family member, friend, attorney, or doctor — to help file and manage your appeal on your behalf.
If you are being discharged from a hospital or losing home health, skilled nursing, or hospice services too soon, you have the right to request a fast (expedited) appeal, often by the day of discharge or the day before your coverage end date.
To reach Level 3 (a hearing before an Administrative Law Judge), your case must meet a minimum dollar amount in controversy — currently $200 for 2026. To take a case to Federal District Court, the threshold is $1,960 for 2026.
Free help is available through your State Health Insurance Assistance Program (SHIP) and by calling 1-800-MEDICARE (1-800-633-4227).

Publication Summary

Medicare can — and does — deny coverage or payment requests. When that happens, beneficiaries are not simply out of options. The 'Medicare Appeals' booklet published by the Centers for Medicare and Medicaid Services lays out a clear, structured process for challenging those decisions, no matter which type of Medicare coverage you have.

The booklet opens by explaining what qualifies as an appealable decision. You can appeal if Medicare or your plan denies a request for a service, supply, item, or drug you think should be covered; refuses to pay for something you already received; or stops providing coverage for something you believe you still need. The booklet also explains how to appoint a representative — using CMS Form 1696 or a written request — so a trusted person can navigate the process on your behalf.

For people with Original Medicare, appeals follow a five-level path. The first step is a Redetermination requested from the Medicare Administrative Contractor (MAC) within 120 days of receiving your Medicare Summary Notice (MSN). If that decision goes against you, you have 180 days to escalate to a Qualified Independent Contractor (QIC) for a Reconsideration at Level 2. Levels 3 through 5 involve the Office of Medicare Hearings and Appeals (OMHA), the Medicare Appeals Council, and ultimately Federal District Court. At Level 3, cases must meet the current year's minimum dollar threshold — $200 in 2026 — and hearings are typically conducted by phone or video. Federal District Court review requires a minimum of $1,960 in controversy for 2026.

The booklet devotes a full section to expedited appeals, which allow people to push back quickly when they believe a discharge from a hospital, skilled nursing facility, home health agency, or hospice is happening too soon. In a hospital, you should receive a notice called 'An Important Message from Medicare about Your Rights' within two days of admission. To get a fast appeal, you must contact the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) no later than the day of your scheduled discharge. If you meet that deadline, you can remain in the hospital without being charged while the BFCC-QIO reviews your case, generally within one day of receiving the necessary information.

For people with Medicare Advantage or other Medicare health plans, the appeals process begins with an Organization Determination — the plan's initial decision on whether to cover a service. If denied, you can request a Reconsideration from the plan within 60 days. If the plan upholds its denial, your case automatically moves to review by an Independent Review Entity (IRE). From there, the process mirrors the Original Medicare path through OMHA, the Appeals Council, and Federal District Court. Plans must respond to standard service requests within 30 days and to expedited requests within 72 hours when your health could be seriously harmed by a delay.

Medicare drug plan appeals (Part D) begin with a Coverage Determination request and, if denied, move through a Redetermination by the plan, Reconsideration by an IRE, then the same upper levels. Drug appeals also allow for expedited decisions — often within 24 to 72 hours — when waiting could seriously harm your health. The booklet also distinguishes between appeals and grievances, noting that a grievance is the right path for complaints about how a plan operates, rather than disputes about coverage or payment decisions.

Throughout every section, the publication reinforces one practical rule: keep copies of everything you send. It also reminds readers that they can get free help from their state SHIP or by calling 1-800-MEDICARE at any stage of the process.

Frequently Asked Questions

What is the difference between an appeal and a grievance?
An appeal is what you file when you disagree with a coverage or payment decision — for example, when Medicare or your plan refuses to pay for a service or drug. A grievance is a complaint about the way your plan operates, such as poor customer service, long wait times for prescriptions, or a failure to send required notices. They are separate processes handled differently by your plan.

Can someone else file an appeal for me?
Yes. You can appoint a representative — a family member, friend, attorney, advocate, or doctor — to file and manage your appeal on your behalf. To do this, complete CMS Form 1696 ('Appointment of Representative') or submit a written request that includes your Medicare Number, your representative's contact information, and signatures from both of you. In some situations, your treating doctor can request certain appeals without being formally appointed.

What happens if I miss an appeal deadline?
Missing a deadline does not necessarily mean you lose your right to appeal. In many cases, you can still file if you provide a reason for the delay. However, the rules that apply may be different, and you may lose some protections — such as remaining in the hospital without being charged while you wait for a fast appeal decision. It is always better to file on time, and SHIP counselors can help you understand your options if you have missed a deadline.

Do I need a lawyer to appeal a Medicare decision?
No. Many Medicare beneficiaries successfully complete the early levels of the appeals process on their own, often with help from a SHIP counselor. However, at higher levels — particularly Level 3 (ALJ hearing) and Level 5 (Federal District Court) — some people choose to consult an attorney, especially when the dollar amount at stake is significant.

What is an Advance Beneficiary Notice of Noncoverage (ABN)?
An ABN is a written notice your provider gives you before delivering a service that Medicare probably will not cover. It lets you make an informed decision about whether to proceed with the service, knowing you may be responsible for the cost. If you choose to receive the service and ask your provider to submit a claim to Medicare, you retain the right to appeal if Medicare denies payment. If you choose not to have the claim submitted, you give up your right to appeal that denial.