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How Do I Appeal a Denied Medicare Claim?

This step-by-step guide can help you start what could be a lengthy process

12-minute read

Kim Lankford,

Updated June 30, 2025

AARP

Reviewed by

Jane Sung, J.D.

Published December 02, 2022

/ Updated June 30, 2025

Matt Chase

Key takeaways

You have a right to appeal any Medicare denial of a payment.
But sometimes the appeal doesn’t need to be formal.
Learn the steps to make a formal appeal. If you’re late, show good cause.
You can continue to appeal up to four additional times.
Medicare Advantage, Part D have similar steps, an expedited process.

First, know that as a Medicare beneficiary, you have the right to appeal if payment is denied for equipment or services you have received as part of your doctor’s plan of care for you.

This is different from prior authorization, preapproval for medical services or prescription drugs that health insurance plans often require before they’ll cover the cost. Original Medicare rarely requires prior authorization, but it is more common in Medicare Advantage and Part D prescription plans.

Providers generally file for reimbursement from the government, or if you’re participating in a Medicare Advantage or Part D plan, they file with the private insurer that administers your plan. That filing is called a claim.

If the claim is denied, you’ll be on the hook to pay the entire bill, not just what might be your copayment and possibly a deductible. If your doctor considered the equipment or services important enough to recommend that you pursue them, the appeals process could be worth your while.

This process has up to five levels. Each step has specific instructions and time frames.

Need help?

Your State Health Insurance Assistance Program (SHIP) can guide you through any confusion. You can call 877-839-2675 to be connected with free help in your state.
The Medicare Rights Center also has a free national help line. Call 800-333-4114.
You can have a trusted family member, friend, lawyer or physician help you with the process or even act on your behalf. But because of health care privacy laws, you’ll have to fill out Medicare’s Authorization to Disclose Personal Health Information form to allow agency representatives to respond to or correspond with that person instead of you.

What steps should I take if I disagree with a claim decision?

With original Medicare, you may be able to solve some Medicare medical claims issues, such as a payment denial, without going through the appeals process.

When you have a question about a claim, first review your Medicare summary notice (MSN), which lists all services and supplies that providers billed to Medicare on your behalf. Medicare sends this notice to enrollees every three months and breaks out claims for Medicare Part A and Medicare Part B separately.

Your online Medicare account will give you updates more frequently than the paper version. You can access information within 24 hours after a claim is processed.

Medicare Advantage and Part D plans, which you buy from a private insurer, mail you a similar notice each month called an explanation of benefits (EOB). The information in this section is specifically for an MSN.

The first page summarizes all costs for the period, adding this statement: “Did Medicare approve all claims?”

It also shows how much of the annual deductible you’ve paid already. So even if the provider’s claim was approved, you may owe money if you haven’t met an applicable deductible.

The third page has details about the claims, including dates, whether a claim was approved, charges not covered, the amount Medicare paid and the maximum amount you may be billed.

Be aware that the amount you may be billed often is less than what you’ll see if you wait for your provider’s bill. You could be billed less for many reasons, including your Medigap plan, Medicaid, Medicare Savings Program or various types of company or military retiree health insurance taking up the slack.

If your claim was denied, contact the provider — a phone number is on the notice — and ask for further itemization for the claim. Confirm the provider sent the right information to Medicare, and if some of the details are wrong, ask the provider’s billing office to contact Medicare and correct the errors.

Remember to keep copies of all the records and correspondence you’re accumulating. Although your file should follow you through the appeals process, you don’t want to leave that to chance. Supporting documentation will be key to getting a decision in your favor.

How do I file an appeal for my claim?

If you’re in the hospital, you can request a fast appeal if you think you’re being discharged too soon. A notice given to you in the hospital titled “An Important Message From Medicare About Your Rights” points you to the Beneficiary and Family Centered Care Quality Improvement Organization that you’ll contact for the appeal, which should be done on or before the day you’re scheduled to be discharged.

In the few days your appeal is being considered, you won’t have to pay for the additional day or two of your stay except for copays and deductibles. The hospital will detail why it wants the discharge, and the reviewing organization will ask for your opinion.

If the review is not in your favor, you’ll need to leave the hospital or start being billed as of noon the day after the reviewer makes the decision.

For other appeals about services rendered or equipment received, as an original Medicare beneficiary, you have 120 days after receiving the summary notice to file an appeal.

The final page of your notice lists the date that the Medicare claims office must receive your appeal. This appeals level is called redetermination, meaning a Medicare administrative contractor not involved in the initial claim decision will review your claim.

You must file your appeal in writing. The last page of the summary notice lists the steps to take:

1. Circle the services or claims you disagree with on the Medicare summary notice.

2. Explain in writing why you disagree with the decision. Include your explanation on the notice or attach a separate page to the notice if you need more space.

3. Fill in your own or your authorized representative’s full name and phone number and your Medicare number.

4. Include any other information about your appeal. You can ask your doctor, health care provider or supplier for information that will back up your claim and help your case. Write your Medicare number on all documents that you send and make copies for your records.

Mail the notice and all supporting documents to the address listed on the last page of your MSN.

Another option is to file a Form 20027, Medicare Redetermination Request Form. If you need help filing your appeal, you can call 800-MEDICARE or contact your State Health Insurance Assistance Program.

You’ll generally get a decision, called a Medicare redetermination notice, from the administrative contractor within 60 days after receiving your request. If your claim is approved, it will be listed on your next Medicare summary notice.

You have the right to up to five levels of appeals if payment is denied for equipment or services you have received as part of your doctor’s plan of care for you.

If I file my Medicare appeal late, am I out of luck?

Not necessarily. If you can give the reviewer evidence that you had good cause for missing any of the various deadlines in the appeals process, you can get an extension. Those valid reasons include:

You were seriously ill.
Someone in your immediate family died or was seriously ill.
Your Medicare summary notice was mailed to the incorrect address.
Your records were damaged, destroyed or inaccessible because of a regional natural disaster or a personal one such as a house fire.
You needed documents in Braille or your native language to understand them better.
The person you are helping couldn’t read or otherwise understand the information sent.
A previous reviewer never issued a decision, gave incomplete information or offered incorrect information about filing an appeal.

Bolster your request with documentation such as doctors’ letters, hospital bills, death certificates, federal disaster declaration information and insurance claims to help persuade the reviewer.

The list of good cause reasons for missing a deadline is long and includes the death of a Medicare beneficiary. Your survivors can continue to pursue a denial that you consider to be in error even if your passing means that a filing deadline was missed.

What if my claim is rejected again? Can I appeal again?

Yes, if Medicare denies your redetermination request, you have the right to pursue up to four more levels of appeals. The notice you receive with the decision at each level includes instructions for pursuing the next level of appeal.

Level 2, reconsideration

1. File within 180 days of receiving your Medicare redetermination notice.

2. Who reviews the request? A qualified independent contractor (QIC) who didn’t participate in the Level 1 decision.

3. How it happens. The contractor will review your written request, including your explanation of why you disagree with the Level 1 decision. Information you submitted at Level 1 will be sent to the contractor to review, and you can also send additional information that may help your case.

4. When to expect a ruling. Expect it in writing about 60 days after the independent contractor gets your appeal request.

Level 3, Office of Medicare Hearings and Appeals

1. File within 60 days of receiving the reconsideration decision if your claim is worth at least $190.

2. Who reviews the request? An administrative law judge in the Office of Medicare Hearings and Appeals, which is independent from the Centers for Medicare & Medicaid Services (CMS).

3. How it happens. You present your testimony to the administrative law judge in a hearing, usually via phone or videoconference. The judge reviews the facts of your appeal before making a new decision. You can have a lawyer represent you.

4. When to expect a ruling. Within 90 days, or you can appeal to the next level.

Level 4, Medicare Appeals Council

1. File within 60 days after receiving the administrative law judge’s decision.

2. Who reviews the request? Administrative appeals judges, independent from both CMS and the Office of Medicare Hearings and Appeals but within the federal Department of Health and Human Services.

3. How it happens. These judges review written materials from your previous appeals and your statement explaining why you disagree with the Level 3 decision.

4. When to expect a ruling. Within 90 days, or you can appeal to the next level if your claim is worth at least $1,900 in 2025.

Level 5, judicial review

1. File within 60 days if your claim is worth at least $1,900 in 2025. Follow the directions in the Appeals Council’s decision letter.

2. Who reviews the request? A federal judge in the district where you live.

3. How it happens. Your disputed claim becomes a civil case filed in U.S. District Court. Also be aware that a provider of services with a previous unfavorable ruling is allowed to request this judicial review.

4. When to expect a ruling. The federal Social Security Act, which was expanded to cover Medicare in 1965, does not specify a time frame for a judge to issue a decision.

What if I have a Medicare Advantage or Part D plan?

The steps above are for appealing claims decisions in original Medicare and don’t apply to claims filed through a private Medicare Advantage plan or a Part D prescription plan. But the process is similar for both of those programs.

A company’s officials review your appeal in Level 1, called a reconsideration rather than the redetermination used in original Medicare. The time frame to start the appeals process is shorter than for original Medicare, only 60 days from the date of your plan’s decision, which is called an organization determination.

If your insurer agrees with your appeal, you’ll be notified of that. If the company denies your appeal in full or in part, you’ll get an automatic appeal to Level 2, an independent review entity that solicits responses from your insurer as well as potential providers of your services and supplies, and notification of this next step in the process.

The remaining levels are the same as for original Medicare. You’ll have to initiate the appeals.

What if I need to know the answer to an appeal immediately?

If your claim involves a prescription drug or service that you need now and can’t wait to receive after you go through a 30-day standard appeals process, you can request expedited action through your Medicare Advantage or Part D plan. You’ll know the result in as little as 72 hours, but that time can extend to 14 days if plan officials need more information from you or your providers.

Your doctor will need to tell your plan that waiting may jeopardize your life, health or ability to recover fully.

Review the denial notice or contact your plan for more information about the steps and deadlines for filing an appeal.

This story, originally published Dec. 2, 2022, was updated with information about authorizing a trusted individual to communicate with Medicare for you, good cause reasons for missing filing deadlines and 2025 claim thresholds.

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About the author

Kimberly Lankford is a contributing writer who covers Medicare and personal finance. She wrote about insurance, Medicare, retirement and taxes for more than 20 years at Kiplinger’s Personal Finance and has written for The Washington Post and Boston Globe. She received the personal finance Best in Business award from the Society of American Business Editors and Writers and the New York State Society of CPAs’ excellence in financial journalism award for her guide to Medicare.

About the reviewer

Jane Sung, director of health care costs and access at the AARP Public Policy Institute, previously worked as health policy counsel at the National Association of Insurance Commissioners, senior policy adviser to a leader in the House of Representatives and federal legislative analyst in the Maryland governor’s office. She earned her law degree from American University’s Washington College of Law.