How to Appeal a Medicare Claim Denial: A Step-by-Step Guide
How to Appeal a Medicare Claim Denial: A Step-by-Step Guide
Your parent's Medicare claim for skilled nursing care gets denied. The explanation of benefits arrives with a cryptic code and a paragraph of legalese. The natural reaction is to assume the decision is final — but it isn't. Medicare's own data shows that roughly 50% of first-level appeals are decided in the beneficiary's favor. The system is designed to be appealed. Most families just don't know how.
Medicare has a five-level appeals process, and each level has strict deadlines. Missing a deadline by even one day can forfeit your right to appeal. Here's exactly how the process works.
Level 1: Redetermination
This is your first appeal, and it's the simplest. You're asking the same entity that denied the claim — the Medicare Administrative Contractor (MAC) for Original Medicare, or the plan itself for Medicare Advantage — to take another look.
Deadline: 120 days from the date on the Medicare Summary Notice (MSN) or Explanation of Benefits (EOB).
How to file: Write a letter stating the claim number, the date of service, why you believe the denial was incorrect, and what medical evidence supports coverage. Attach supporting documentation — physician letters, medical records, lab results, or clinical notes that weren't included in the original submission.
For Medicare Advantage and Part D denials, call the plan's member services number on your parent's insurance card and ask for the appeals department. Most plans also accept appeals by fax or through their member portal.
Turnaround: The MAC or plan must respond within 60 days for Part A and Part B claims, 7 days for pre-service requests, and 72 hours for expedited requests involving urgent health situations.
Tip: Request an expedited appeal if your parent is currently receiving the service that was denied (such as skilled nursing care) and stopping treatment would jeopardize their health. An expedited request forces a decision within 72 hours.
Level 2: Reconsideration by a Qualified Independent Contractor (QIC)
If the redetermination upholds the denial, the next step is an independent review by a QIC — an organization contracted by CMS that has no affiliation with the MAC or the plan that denied the claim.
Deadline: 180 days from the date of the Level 1 decision.
How to file: The Level 1 denial letter includes instructions for requesting reconsideration. Submit a written request to the QIC identified in that letter, along with any additional medical evidence you've gathered since the first appeal.
Turnaround: 60 days for most claims.
This level is where many denials get overturned, because the reviewer is independent. Include everything — progress notes, therapy evaluations, attending physician statements explaining medical necessity. The QIC reviewer has never seen the case before and will base their decision entirely on what you submit.
Level 3: Administrative Law Judge (ALJ) Hearing
If the QIC upholds the denial and the amount in dispute meets the minimum threshold ($180 for 2026), you can request a hearing before an Administrative Law Judge at the Office of Medicare Hearings and Appeals (OMHA).
Deadline: 60 days from the Level 2 decision.
How to file: Submit a request for hearing using form OMHA-100 to the Office of Medicare Hearings and Appeals.
Format: Hearings are typically conducted by phone or video conference. You or your representative can present testimony, submit additional evidence, and question witnesses. Your parent does not need to attend — you can represent them if you've filed Form CMS-10106 (Appointment of Representative).
Turnaround: OMHA's statutory goal is 90 days, though backlogs can extend this to several months.
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Level 4: Medicare Appeals Council Review
If the ALJ rules against you, the Medicare Appeals Council can review the decision.
Deadline: 60 days from the ALJ decision.
This is a paper review — no hearing. The Council examines whether the ALJ applied the law correctly and whether the evidence supports the decision. They can affirm, reverse, or remand the case back to the ALJ.
Level 5: Federal District Court
For claims exceeding $1,840 (2026 threshold), the final appeal level is federal court.
Deadline: 60 days from the Appeals Council decision.
This is rarely necessary for individual claim disputes, but it exists as a final safeguard.
Special Rules for Dual-Eligible Beneficiaries
If your parent is on both Medicare and Medicaid, the appeals landscape has additional layers:
Who pays during the appeal? For dual-eligible beneficiaries enrolled in a D-SNP (Dual Eligible Special Needs Plan), the plan must continue providing the disputed service while the appeal is pending if your parent was already receiving it. This is called "continuation of benefits" or "aid continuing." You must specifically request it when filing the appeal.
QMB billing disputes. If your parent has Qualified Medicare Beneficiary status and a provider sends them a bill for Medicare cost-sharing (deductibles, copays, or coinsurance), this is illegal under federal law. You don't need to appeal — you need to report it. Contact 1-800-MEDICARE and file a complaint. The provider is prohibited from billing QMB patients for any Medicare cost-sharing, regardless of whether the provider participates in Medicaid.
Medicaid service denials. If the denial involves a Medicaid-funded service (such as home care hours or nursing home coverage), you appeal through the state Medicaid fair hearing process, not through Medicare. These are separate systems with different deadlines and procedures.
Practical Tips for Winning Appeals
Get the physician involved. A letter from your parent's attending physician explaining why the service is medically necessary is the single most powerful piece of evidence. Ask the doctor to reference specific diagnoses, functional limitations, and clinical guidelines.
Cite Medicare's own coverage criteria. Every coverage decision is based on a National Coverage Determination (NCD) or Local Coverage Determination (LCD). Look up the relevant LCD for the denied service and show how your parent meets each criterion.
Don't give up at Level 1. The first denial is often procedural — a missing code, an incomplete submission, or a cursory review. The independent review at Level 2 is where the merits of the case are evaluated fresh.
The Dual Eligible Coordination Guide includes a complete appeals chapter covering deadlines, form references, and sample language for appeal letters at each level.
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