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Receiving a denial notice for a Medicare or Medicaid claim can feel overwhelming, but you have every right to challenge decisions you believe are wrong. Most people don’t realize that appeals are often successful. According to reports, approximately 80% of appeals regarding hospital discharge decisions are decided in the beneficiary’s favor, and 82% of Medicare appeals result in full or partial overturns of initial denials.
Understanding the appeals process and acting promptly can make the difference between paying out-of-pocket and getting the coverage you deserve.
Understanding Why Claims Get Denied
Before filing an appeal, it’s crucial to understand why your claim was denied. Common reasons include:
Medical Necessity Issues: Medicare or Medicaid determined the treatment wasn’t medically necessary for your condition.
Documentation Errors: Missing, incomplete, or incorrectly filed paperwork that didn’t provide sufficient information.
Coding Mistakes: Errors in billing codes that led to automatic claim rejection.
Coverage Limitations: The service isn’t covered under your specific Medicare or Medicaid plan.
Timing Issues: Claims filed after deadlines or services provided outside coverage periods.
Review your denial notice carefully. It will explain the specific reason for the denial and cite the rules used to make the decision.
Medicare Appeals Process: Five Levels of Review
Medicare offers a structured five-level appeals process. You can move to the next level if you’re unsatisfied with any decision.
Level 1: Redetermination by Medicare Administrative Contractor
Deadline: 120 days from the date on your Medicare Summary Notice (MSN)
Process: A different Medicare Administrative Contractor (MAC) employee reviews your claim
Decision Timeline: 60 days
How to File:
- Circle the denied services on your MSN
- Complete Form CMS-20027 (Medicare Redetermination Request Form)
- Explain in writing why you disagree with the decision
- Include supporting documentation like medical records or doctor’s notes
- Mail to the address listed on your MSN
Tip: Send your appeal via certified mail with return receipt to confirm delivery.
Level 2: Qualified Independent Contractor (QIC) Reconsideration
Deadline: 180 days from receiving the MAC decision
Process: An independent contractor reviews your case with fresh eyes
Decision Timeline: 60 days
Requirements: No minimum dollar amount needed
The QIC provides an independent medical review, particularly valuable for medical necessity disputes.
Level 3: Administrative Law Judge (ALJ) Hearing
Deadline: 60 days from receiving the QIC decision
Minimum Amount: $190 in 2025 (you can combine claims to meet this threshold)
Process: Hearing before an Administrative Law Judge through the Office of Medicare Hearings and Appeals (OMHA)
Decision Timeline: 90 days (though delays are common)
You can request a hearing by phone, video conference, or in-person, or ask for a decision without a hearing based on written records.
Level 4: Medicare Appeals Council Review
Deadline: 60 days from receiving the ALJ decision
Process: Review by the Appeals Council within the Department of Health and Human Services
Timeline: No specific timeframe required
Level 5: Federal District Court
Deadline: 60 days from receiving the Appeals Council decision
Minimum Amount: $1,900 in 2025
Process: Your case becomes a civil lawsuit in federal court

Medicaid Appeals Process
Medicaid appeals vary by state, but all states must provide a fair hearing process for beneficiaries.
Initial Steps
Review Your Denial Notice: The notice must explain why you were denied, what rules were used, and your appeal rights.
Timing is Critical: Most states require appeals within 90 days or less. Some situations require filing within 10 days to continue receiving benefits during the appeal.
File in Writing: While not always required, written appeals provide better documentation. Sign and date your appeal before submitting it.
State Fair Hearing Process
Pre-Hearing Options: Sometimes Medicaid representatives will contact you after receiving your appeal to negotiate a settlement.
Prepare for Your Hearing: Review your file and gather supporting documents. You can request a postponement if you need more time to prepare.
Representation: You can represent yourself, but consider getting help from a legal aid office, especially for complex cases.
Aid Paid Pending: If your current benefits are being reduced or terminated, you may be able to continue receiving them during the appeal process.
Essential Tips for Successful Appeals
Document Everything
- Keep copies of all correspondence, including denial notices
- Maintain detailed records of phone calls with dates and representatives’ names
- Gather supporting medical records, lab results, and physician statements
- Request your complete file from Medicare or Medicaid before your hearing
Meet All Deadlines
Missing deadlines is the most common reason appeals fail. Mark deadlines on your calendar and file appeals well before the due date.
Good Cause Extensions: If you miss a deadline due to illness, family emergency, or postal delays, you may request a “good cause” extension. Include documentation supporting your reason for the delay.
Strengthen Your Case
- Ask your doctor to provide a detailed statement explaining why the service was medically necessary
- Include any additional test results or medical evidence that supports your case
- Address the specific reason for denial mentioned in the notice
- Be clear and concise in your written explanations
Get Help When Needed
State Health Insurance Assistance Program (SHIP): Free counseling available by calling 1-800-MEDICARE or visiting shiphelp.org
Legal Aid: Many legal aid offices provide free or low-cost representation for Medicaid appeals
Patient Advocates: Professional advocates can help navigate the appeals process and represent you at hearings
Expedited Appeals for Urgent Situations
Both Medicare and Medicaid offer expedited (fast) appeals when your health could be seriously harmed by waiting for a standard decision.
Medicare Expedited Appeals: Decisions within 72 hours for coverage determinations, 24 hours for some situations
Requirements: Your doctor must certify that waiting could jeopardize your life, health, or ability to recover
What to Expect During the Process
Stay Organized: Keep a file with all appeal-related documents in chronological order
Continue Treatment: Don’t stop necessary medical care while your appeal is pending. In some cases, you can continue receiving services during the appeal process
Follow Up: Contact the reviewing entity if you don’t receive decisions within the stated timeframes
Consider Settlement: Sometimes appeals can be resolved through negotiation before reaching a formal hearing
After Your Appeal Decision
If You Win: Your service will be covered, and you should receive reimbursement for any payments you made
If You Lose: You can move to the next appeal level if you meet the requirements and deadlines
Partial Wins: Sometimes appeals result in partial coverage, which may still provide significant financial benefit
Remember that persistence often pays off in the appeals process. Many denials are overturned at higher levels of review, so don’t give up if your initial appeal is unsuccessful. Each level provides a fresh perspective and independent review of your case.