The Medicare plan member, the member's appointed representative, or, in some cases, the member's doctor can submit an appeal request.
There are five levels in the appeals process:
| Level | Standard Appeal | Expedited Appeal* | |
| 1 | Redetermination by the Plan | If the plan’s coverage determination is unfavorable, a member or a member's representative may request a standard redetermination request within 65 days of the negative Coverage Determination. The plan has up to 7 days to issue its decision. | Same as standard appeal except the member’s doctor may also request an expedited redetermination. The plan has up to 72 hours to issue its decision. |
| 2 | Reconsideration by the Part D Qualified Independent Contractor (QIC) also known as Independent Review Entity (IRE) |
If the plan’s redetermination is unfavorable, a Medicare plan member or a member's appointed representative or the member's doctor have 60 days to request a reconsideration by the Part D Independent Review Entity (IRE also sometimes called Part D QIC), which is a CMS contractor that reviews plan decisions. The IRE has up to 7 days to issue its decision. | Same as standard appeal except the time frame is up to 72 hours for the IRE / Part D QIC to issue its decision. |
| 3 | Decision by the Office of Medicare Hearings and Appeals (OMHA) before an Administrative Law Judge (ALJ) | If the IRE / Part D QIC’s reconsideration is unfavorable (within 60 days), a member or a member's appointed representative can request a hearing with an ALJ if the amount remaining in controversy requirement is satisfied. | Not applicable. |
| 4 | Review by Medicare Appeals Council (MAC) | If the ALJ’s finding is unfavorable, a member or a member's appointed representative has 60 days to appeal to the MAC, an entity within the Department of Health and Human Services that reviews ALJ decisions. | Not applicable. |
| 5 | Federal district court judicial review |
If the MAC’s decision is unfavorable, a member or a member's appointed representative has 60 days to appeal to a Federal district court, if the amount remaining in controversy requirement is satisfied ($1,840 in 2024). | Not applicable. |
*An expedited decision is requested based on the urgency of a member's health condition. As noted by the Centers for Medicare and Medicaid Services (CMS):
Five (5) things to know when filing an appeal
- If you decide to file an appeal, ask your doctor, health care provider, or supplier for any information that may help your case.
- If you think your health could be seriously harmed by waiting for a decision about a service, ask the plan for a fast decision. If the plan or doctor agrees, the plan must make a decision within 72 hours.
- The plan must tell you, in writing, how to appeal. After you file an appeal, the plan will review its decision. Then, if your plan doesn't decide in your favor, the appeal is reviewed by an independent organization that works for Medicare, not for the plan.
- If you believe you're being discharged from a hospital too soon, you have a right to immediate review by your Beneficiary And Family Centered Care Quality Improvement Organization (BFCC-QIO). You'll be able to stay in the hospital at no charge while they review your case. The hospital can't force you to leave before the BFCC-QIO reaches a decision.
- You'll have the right to a fast-track appeals process when you disagree with a decision that you no longer need services you're getting from a skilled nursing facility, home health agency, or a comprehensive outpatient rehabilitation facility.
Yes. As noted, you can appoint a representative to help you file an appeal. Your representative can be a family member, friend, advocate, attorney, financial advisor, doctor, or someone else who will act on your behalf.
You can also contact your State Health Insurance Assistance Program (SHIP) if you need help filing an appeal.
Question: How do I appoint a representative who can file my appeal?
- Fill out an "Appointment of Representative" form [PDF, 47.7KB]. Send the representative form or written request with your appeal to the
Medicare Administrative Contractor (MAC) (the company that handles
claims for Medicare), or your Medicare health plan.
- You can use your online Medicare account to add your representative.
- Or, submit a written request with your appeal that includes:
- Your name, address, phone number, and Medicare Number
- A statement appointing someone as your representative
- The name, address, and phone number of your representative
- The professional status of your representative (like a doctor) or their relationship to you
- A statement authorizing the release of your personal and identifiable health information to your representative
- A statement explaining why you’re being represented and to what extent
If you have questions about appealing a Coverage Determination or appointing a representative, you can call a Medicare representative at 1-800-MEDICARE (1-800-633-4227). TTY: 1-877-486-2048.
Sources include:
CMS, U.S. Department of Health & Human Services