Medicare’s 5-Level Appeal Process

If you have a service that's denied by Medicare, or if you felt like you paid too much for a particular prescription, or medical device, or let's say a procedure or doctor's visit, there are five levels of appeals that somebody can go through with Medicare.

A lot of times folks will appeal a decision if they felt like it was an erroneous decision and then they'll just give up if they get a denial to that appeal. Don’t give up! Here are the 5 levels of Medicare appeals somebody can go through:

Level 1: Reconsideration from your plan

When your Medicare health plan denies coverage for a service or item, the first step is to request a reconsideration from your plan. This involves reviewing your case with any new evidence or medical documentation you can provide. It’s essential to submit this request within 60 days of receiving the initial denial notice. The health plan must respond within 30 days for standard service requests or within 72 hours for expedited requests​ (Medicare)​.

Level 2: Review by an Independent Review Entity (IRE)

If your plan upholds its denial at Level 1, you can escalate your appeal to an Independent Review Entity (IRE). The IRE conducts an impartial review of your case, examining all evidence from both you and your health plan. Similar to Level 1, you must submit your request for an IRE review within 60 days of the Level 1 decision. The IRE is required to issue a decision within 30 days for standard cases or within 72 hours for expedited cases​ (Medicare)​.

Level 3: Decision by the Office of Medicare Hearings and Appeals (OMHA)

Should the IRE uphold the denial, the next step is to request a hearing with an Administrative Law Judge (ALJ) within 60 days of the IRE decision. The Office of Medicare Hearings and Appeals (OMHA) handles these hearings, which can be conducted by video conference, phone, or in person. You can present new evidence, and the ALJ will issue a decision based on the hearing and submitted documents. The process can take several months due to the high volume of cases​ (Medicare)​.

Level 4: Review by the Medicare Appeals Council (Appeals Council)

If the ALJ’s decision is unfavorable, you can request a review by the Medicare Appeals Council within 60 days. The Council will review the ALJ’s decision and any additional information you provide. They may either issue a decision, return the case to the ALJ for further review, or dismiss the case. This level is typically more procedural and focuses on whether the ALJ’s decision followed proper guidelines​ (Medicare)​.

Level 5: Judicial review by a federal district court

The final level of appeal is seeking judicial review in a federal district court. This step is only available if the amount in controversy meets a minimum threshold, which for 2024 is $1,840. To proceed, you must file a complaint in the federal district court within 60 days of receiving the Medicare Appeals Council’s decision. This level involves a more formal legal process, and you may want to seek legal assistance to navigate it effectively​ (Medicare)​.