How to Appeal a Medicare Claim Denial: The Five Levels, Deadlines and What to Send

To appeal a Medicare claim denial, you ask the Medicare Administrative Contractor (MAC) that denied it for a redetermination, in writing, within 120 days of receiving the denial. That is the first of five levels in the Original Medicare (Part A and Part B) appeals process. Most practices never need the later levels, but every level has its own deadline, and missing one usually ends the appeal. This guide covers how to appeal a Medicare claim denial step by step: when an appeal is the wrong tool, the five levels with their deadlines and dollar thresholds, and what to put in the packet.

Should you appeal, reopen or correct?

Check this first, because an appeal is the slowest route and not always the right one.

• A clerical error (a wrong code, a typo, a missing modifier) can usually be fixed with a reopening instead. Noridian, for example, accepts reopenings within one year from the initial determination and has 60 days to complete them. Some changes cannot be made as a reopening, such as adding claim lines, and those go to a redetermination.
• A rejection never became a claim, so there is nothing to appeal. Fix it and send it again. Our article on claim rejection vs denial explains the difference.
• A late-filing denial cannot be appealed at all. It is not an initial determination, so the only way back is one of the narrow exceptions to the Medicare timely filing limit.
• A decision you disagree with, such as medical necessity, coverage or a bundling edit you believe does not apply, is what appeals are for.

The five levels of Medicare appeal

Each level starts when you receive the decision from the level before. Medicare presumes you received a notice 5 calendar days after the date printed on it, unless you can show otherwise.

Sources: CMS pages for level 1, level 2, level 3, level 4 and level 5, and the 2026 threshold notice. The 2027 thresholds apply to requests filed on or after January 1, 2027.

Level 1: Redetermination

File with the MAC that made the decision; its name is on the remittance advice. You can use form CMS-20027 or write a letter. There is no minimum dollar amount. The MAC generally decides within 60 days.

Level 2: Reconsideration

If the redetermination goes against you, ask the QIC within 180 days, on form CMS-20033 or by letter. Include any documentation the redetermination notice said was missing. This level matters more than it looks: CMS warns that records you do not submit here may be excluded at later levels unless you show good cause. If the QIC cannot decide in time, it must tell you, and you can ask to move the appeal up to the next level.

Level 3: Hearing at OMHA

Request a hearing within 60 days on form OMHA-100. The amount in controversy must be at least $200. Hearings are usually held by telephone. A decision generally comes within 90 days of the request, though that can be extended, and if OMHA misses its deadline you can ask to move the appeal to the Council.

Level 4: Medicare Appeals Council

Ask within 60 days on form DAB-101. The Council generally decides within 90 days, or 180 days for an appeal escalated from OMHA. If it misses its deadline, you can ask to move the case to federal court.

Level 5: Federal court

File a civil action within 60 days of receiving the Council's decision. The amount in controversy must be at least $1,960 for 2026 filings and $2,000 for 2027 filings. At this level, talk to your health care counsel first.

What to include in a Medicare appeal

A complete first request saves you from needing a second. CMS lists what a written request must contain, and a strong packet adds the evidence behind it.

1. The patient's name and Medicare number.
2. The service and the date of service you are appealing, line by line.
3. Your name (or your representative's) and the contractor that made the decision.
4. Why you disagree, in plain sentences tied to the denial reason and remark codes. "The service was medically necessary because..." beats "Please reconsider."
5. The remittance advice or decision notice you are appealing.
6. The medical records that prove the point: the signed note, the order, test results, and for time-based or monitoring services, the time and reading logs.
7. The coverage rule you are relying on, such as the relevant national or local coverage determination, quoted briefly.
8. Anything the notice said was missing. If the denial named a missing document, send that document.

Keep a copy of the whole packet and proof of the date you sent it. Our guide to common claim denial reasons explains how to read the codes before you write the argument.

What about overpayment demands?

An appeal also works when Medicare says it overpaid you and wants money back. Filing a timely redetermination request stops the contractor from recouping the overpayment while the appeal is pending, under 42 CFR 405.379. The deadlines for stopping recoupment are tighter than the 120-day appeal window, so read the demand letter the day it arrives and check its dates.

Frequently asked questions

How long do I have to appeal a Medicare claim denial?

You have 120 days from receiving the initial determination to request a redetermination from your Medicare contractor. Medicare presumes you received the notice 5 days after its date unless you show otherwise.

What are the five levels of Medicare appeals?

Redetermination by the Medicare Administrative Contractor, reconsideration by a Qualified Independent Contractor, a hearing at the Office of Medicare Hearings and Appeals, review by the Medicare Appeals Council, and judicial review in federal district court.

Is there a minimum amount to appeal a Medicare claim?

Not for the first two levels. A hearing at the third level requires at least $200 in controversy in 2026 and 2027, and federal court requires at least $1,960 in 2026 and $2,000 in 2027.

Should I appeal or reopen a Medicare claim?

Use a reopening for clerical errors such as a wrong code or a typo, usually within one year of the initial determination. Use an appeal when you disagree with Medicare's decision, such as a medical necessity denial.

Can I add new records at a later appeal level?

Sometimes, but do not count on it. Records not submitted at the reconsideration level may be excluded from later levels unless you show good cause, so send everything you have by the second level.

Sources

• First Level of Appeal: Redetermination by a Medicare Contractor, CMS
• Second Level of Appeal: Reconsideration by a Qualified Independent Contractor, CMS
• Third Level of Appeal: Decision by Office of Medicare Hearings and Appeals (OMHA), CMS
• Fourth Level of Appeal: Review by the Medicare Appeals Council, CMS
• Fifth Level of Appeal: Judicial Review in Federal District Court, CMS
• Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2026, Federal Register
• 42 CFR 405.379, Limitation on recoupment of provider and supplier overpayments, Code of Federal Regulations
• 42 CFR 405.926, Actions that are not initial determinations, Code of Federal Regulations
• 42 CFR 405.980, Reopening of initial determinations, Code of Federal Regulations