Appeal process · Medicare

The five levels of Medicare appeals

Medicare appeals are a defined, five-level ladder with its own deadlines at each rung. Knowing which level you're on — and what it takes to climb to the next — is half the battle.

Medicare fee-for-service (Parts A and B) appeals proceed through five levels, each with its own decision-maker and deadline. Medicare Advantage (Part C) has a parallel five-level structure that starts with the plan and escalates to an Independent Review Entity. The first level is where most appeals are won or lost, so it pays to make it complete.

The five levels (fee-for-service)

  1. 1

    Redetermination — by the MAC

    The first appeal, decided by the Medicare Administrative Contractor. The request is generally due within 120 days of the initial determination (42 CFR 405.942).

  2. 2

    Reconsideration — by a QIC

    An independent Qualified Independent Contractor reviews the redetermination; generally due within 180 days of the redetermination notice.

  3. 3

    ALJ hearing — OMHA

    A hearing before an Administrative Law Judge at the Office of Medicare Hearings and Appeals, subject to a minimum amount-in-controversy.

  4. 4

    Medicare Appeals Council

    Review by the Council (Departmental Appeals Board) of the ALJ decision.

  5. 5

    Federal district court

    Judicial review, subject to a higher amount-in-controversy threshold.

Medicare Advantage is its own ladder

Part C (Medicare Advantage) appeals start with a reconsideration by the plan itself; if upheld, the case is automatically forwarded to an Independent Review Entity, then up through ALJ, Council, and federal court. MA filing windows are shorter than fee-for-service — generally 60 days to request the plan-level reconsideration (42 CFR 422.582).

Watch the deadline for the plan type

Fee-for-service Medicare gives 120 days for the first appeal; Medicare Advantage gives 60. Filing under the wrong clock is a common, avoidable loss.

Frequently asked

Which level do most appeals win at?
The first level (redetermination, or the plan reconsideration in MA) is where a complete, well-documented appeal most often succeeds — so make it thorough rather than treating it as a formality.
How long do I have to file the first Medicare appeal?
Fee-for-service: generally 120 days from the initial determination (42 CFR 405.942). Medicare Advantage: generally 60 days for the plan reconsideration (42 CFR 422.582).

Primary sources: 42 CFR 405.942 (time limit for filing a redetermination); 42 CFR 422.582 (Medicare Advantage reconsideration). General information, not legal or medical advice — confirm against the governing rule for the plan type.

Related guides

Appeal deadlines by plan typeMedicare fee schedule & allowed amountsCO-45 · Allowed amount

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