Medicare Appeals: The Five Levels of Review

A Medicare denial is the start of a process, not the end of one. Five levels of review exist, in a fixed order: redetermination by the Medicare Administrative Contractor that processed the claim; reconsideration by a Qualified Independent Contractor; a hearing before an administrative law judge at the Office of Medicare Hearings and Appeals; review by the Medicare Appeals Council within the Departmental Appeals Board; and a civil action in federal district court. Each level has its own filing window and its own decision-maker, and two of the five will not open at all unless the amount in dispute is large enough. Separate fast tracks run alongside for discharge and service-termination disputes.

1.The ladder

The sequence is the same whether the dispute began as a denied hospital claim, a denied outpatient service, a plan refusal, or a drug that a pharmacy would not fill. Only the first two rungs change shape depending on which part of Medicare is involved.

1. Redetermination. The contractor that denied the claim reviews it again, using staff who did not make the first decision. The request goes in writing, within the period stated on the summary notice.
2. Reconsideration. A Qualified Independent Contractor, a different company entirely, reviews the file. This is the step where the record is built, because evidence held back here can be excluded later without good cause.
3. Administrative law judge hearing. A hearing at the Office of Medicare Hearings and Appeals, usually by telephone or video. This is the first stage with live testimony and questions.
4. Medicare Appeals Council. Review on the record by the Council within the Departmental Appeals Board. No new hearing, and new evidence is accepted only in narrow circumstances.
5. Federal district court. A civil action, filed after the Council decides or after it declines to review within its own period.

Parts A and B follow that path directly. In Part C, a Medicare Advantage plan makes the first decision and its own reconsideration, and an upheld denial is forwarded automatically to an independent review entity that stands in for the second level — a structure described in more detail in the entry on organization determinations. Part D drug appeals start with a coverage determination by the plan, then a plan redetermination, then the same kind of independent review. All three routes merge at the judge.

These rules are federal and uniform; there is no state variation in how the five levels operate. State law still matters at the edges. A Medigap policy that pays what Medicare leaves is regulated by the state insurance department, state balance-billing and consumer-protection statutes govern what a provider may collect from a patient in some states, and a person enrolled in both Medicare and Medicaid has a separate state fair-hearing right on its own track. Enrollment questions, as opposed to coverage disputes, go to the Social Security Administration.

2.Where the ladder narrows

Levels one and two are open to any denied claim. Levels three and five are not. Both the administrative law judge hearing and the federal court action require a minimum amount in controversy, and those minimums are adjusted every year. Never work from a figure you remember; the current amounts are published by the Centers for Medicare and Medicaid Services and summarized in the appeal instructions on Medicare.gov.

The five-level structure itself has been stable for many years and remains in place as of mid-2026; it is the thresholds, not the ladder, that move.

Two features soften the gate. Claims may sometimes be aggregated, so a series of small recurring denials — the same supply refused month after month, the same therapy visit denied week after week — can be combined to reach the threshold. And the threshold is measured by the amount still in dispute, not the original billed charge, so partial payments along the way reduce what remains and can quietly close the door.

Deadlines at each level are set by regulation and stated on the notice. Read the notice for the date rather than assuming the interval, and if one has already passed, ask in writing and give the reason, because good cause for late filing is a recognized category rather than a favor.

3.The fast tracks

Two situations cannot wait for a ladder measured in months, and Medicare handles them separately. Both are triggered by a written notice you should receive before the care stops.

Hospital discharge

An inpatient who believes discharge is premature can ask the Beneficiary and Family Centered Care Quality Improvement Organization for an immediate review. The request must be made quickly, on the schedule stated in the notice given at admission and again before discharge. While the review is pending, the beneficiary generally is not liable for the cost of continued stay.

Termination of skilled nursing, home health, or hospice services

The provider must give advance written notice that covered services are ending. The beneficiary can ask the same Quality Improvement Organization for an expedited determination, on a clock measured in days rather than weeks. Services generally continue while that review runs.

These reviews do not replace the five levels. An unfavorable expedited determination can still be carried forward through reconsideration and onward. What they buy is time, and time is usually the thing in shortest supply when a facility has set a discharge date.

Caution: The fast-track request must be made within the short window stated on the notice, and that window is often measured from the day the notice is delivered rather than the day services would end. Missing it does not end the appeal, but it does end the right to have services continue while the appeal is decided.

4.What moves a judge

By the third level, the file is fixed and the argument is about coverage criteria applied to documented facts. Cases turn on a small number of recurring things.

The clinical documentation has to say what the coverage rule requires. A therapy note that records attendance but not function, or a physician order without the underlying assessment, loses to a well-documented file even where the underlying care was plainly appropriate. Getting the complete chart early is part of the appeal, which is why the right of access to your own medical records, explained further on the HHS page for individuals, is a practical appeal tool rather than a formality.

Coverage policy also does different work at different levels. National coverage determinations bind the administrative law judge. Local coverage determinations do not bind the judge in the same way, though they are given substantial deference, which means a well-supported argument that a local policy does not fit the clinical facts is one of the few genuinely open arguments at this stage.

Finally, someone has to appear. A representative may be appointed in writing, and a treating clinician's testimony about medical necessity carries weight that a written letter often does not. Hearings are typically held by telephone or video, so appearing is usually a scheduling question rather than a travel one.

5.Questions this raises

Can the treating doctor file the appeal instead of the patient?

A provider can appeal in its own right when it has taken assignment of the claim, and can also act for the beneficiary if appointed as representative in writing. The two routes are not identical: a provider appealing its own payment controls the argument, while an appointed representative acts for the beneficiary and the beneficiary retains the underlying rights. Where both have an interest, put the appointment in writing early to avoid a dispute about who is filing.

Does new evidence get in at the administrative law judge level?

It can, but not freely. Evidence a beneficiary or provider had available at the reconsideration stage and did not submit may be excluded absent good cause, and the Medicare Appeals Council applies a stricter rule again. The practical lesson is to treat the second level as the moment to complete the file: every clinical note, every order, every measurement that supports the coverage criteria, submitted then rather than saved for the hearing.

What happens to the bill while the appeal is running?

It depends on the track. Under the expedited discharge and service-termination reviews, the beneficiary is generally protected from liability while the review is pending. In an ordinary claim appeal there is no automatic hold, and a provider may bill. Some states restrict collection activity on a disputed bill under their own consumer-protection statutes, so the answer to what a provider may actually do partly depends on where the care was furnished.

Is a Part D drug denial handled the same way?

The upper levels are identical, but the entry point differs. A Part D dispute starts with a coverage determination request to the plan, which includes exception requests for a drug not on the formulary or for a tiering change, supported by the prescriber's statement. If the plan says no, the next step is a plan redetermination, then independent review, then the same judge, Council, and court. Expedited handling is available where waiting would risk health.

6.If a denial arrives

Read the notice for two things before anything else: the specific reason code or stated ground, and the deadline for the next step. Those two facts determine the entire strategy, and both are printed on the notice rather than left to inference.

Then request the complete records and the plan's or contractor's stated coverage criteria, and build the file to match the criteria point by point. File the redetermination in writing and keep proof of the filing date. Treat the reconsideration as the last free chance to add evidence. If services are ending or a discharge is scheduled, drop the ordinary sequence and use the expedited route in the notice immediately, because that clock is measured in days. Check the current amount-in-controversy figures before assuming a hearing is available, and consider whether repeated small denials can be aggregated to get there. Where the dispute began with a form signed at a clinic desk, keep the advance notice of non-coverage with the file, because its validity is often a second, independent argument.