As a Medicare beneficiary, you have important rights and protections under federal law. Understanding these rights—and knowing how to exercise them when necessary—empowers you to get the coverage and care you deserve. When Medicare or your Medicare plan denies coverage or payment for services you believe should be covered, the appeals process provides a structured path to challenge these decisions. Successfully navigating the appeals system can overturn wrongful denials and save you thousands of dollars.
Your Fundamental Medicare Rights
Medicare law establishes several fundamental rights that all beneficiaries possess. You have the right to be treated with dignity and respect at all times. You have the right to be protected from discrimination. Federal law prohibits healthcare providers from treating you differently based on race, color, national origin, disability, age, sex, or religion.
You have the right to have your personal and health information kept private and confidential in accordance with HIPAA laws. Only people authorized by law or you can access your medical records and health information. You have the right to get information in a way you understand from Medicare, health plans, doctors, and other providers. This includes getting help in your language if you don't speak English and getting information in formats accessible if you have a disability.
You have the right to timely access to covered services and drugs. If your Medicare health plan has a service authorization process, you have the right to get a coverage decision or exception within time frames established by law. You have the right to know your treatment choices and participate in decisions about your healthcare. This includes the right to refuse treatment and get information about the risks and benefits of available treatment options.
You have the right to file complaints and appeals if you disagree with decisions about your healthcare or payment for healthcare. This fundamental right to appeal underlies the entire appeals process and ensures you can challenge decisions you believe are incorrect.
Understanding Medicare Claim Denials
Medicare or your Medicare plan can deny coverage or payment for services for various reasons, including if they determine the service wasn't medically necessary, the service isn't covered by Medicare, you received care from an out-of-network provider (in Medicare Advantage plans), you didn't get required prior authorization (in Medicare Advantage plans), or the service exceeded quantity limits or frequency limits established by Medicare or your plan.
When Medicare or your plan denies coverage or payment, you receive a written notice explaining the denial reason, the specific service or item denied, the denial date, and instructions for filing an appeal. This notice is called a Medicare Summary Notice (MSN) for Original Medicare, an Explanation of Benefits (EOB) for some services, or a denial letter from your Medicare Advantage or Part D plan.
Read these notices carefully as soon as you receive them. The notices include critical information about your appeal rights and deadlines. Missing appeal deadlines means losing your right to challenge the denial. If you don't understand the denial reason or believe it's incorrect, don't assume the decision is final—proceed with an appeal.
Common reasons for denials that are often successfully appealed include incorrect determination that a service wasn't medically necessary when your doctor has documented the medical need, denials based on technical billing errors that can be corrected, denials for services that actually are covered but were miscoded, and denials based on incomplete medical documentation that can be supplemented with additional information from your provider.
The Five Levels of Medicare Appeals
Medicare's appeals process includes five progressive levels. You must proceed through these levels in order, and each level has specific time limits for filing your appeal and for receiving a decision. Understanding this structure helps you navigate the process successfully.
Level 1: Redetermination (Original Medicare) or Reconsideration (Medicare Advantage/Part D) - This first appeal is reviewed by the same organization that made the initial coverage decision, but by different reviewers. For Original Medicare, this is a redetermination by the Medicare Administrative Contractor (MAC). For Medicare Advantage and Part D, it's a reconsideration by your plan.
You have 120 days from the date you receive the denial notice to file a Level 1 appeal. In Original Medicare, the MAC must issue a decision on your redetermination within 60 days for standard requests, or 72 hours for expedited requests if the standard timeframe could seriously jeopardize your life, health, or ability to regain maximum function. For Medicare Advantage and Part D, plans must decide standard appeals within 30 days and expedited appeals within 72 hours.
Level 2: Reconsideration by a Qualified Independent Contractor (Original Medicare) or Independent Review Entity (Medicare Advantage/Part D) - If Level 1 denies your appeal, you can request Level 2 review by an independent organization not affiliated with Medicare or your plan. For Original Medicare, this is a Qualified Independent Contractor (QIC). For Medicare Advantage and Part D, it's an Independent Review Entity (IRE).
You have 180 days from the date of the Level 1 denial to request Level 2 review. QICs and IREs must issue decisions on standard appeals within 60 days for Original Medicare and 30 days for Medicare Advantage/Part D, with expedited review available when health situations require faster decisions.
Level 3: Administrative Law Judge (ALJ) Hearing - If Level 2 denies your appeal and the dollar amount in controversy meets the threshold ($190 for 2025), you can request a hearing before an Administrative Law Judge. ALJ hearings are conducted by the Office of Medicare Hearings and Appeals (OMHA), independent from CMS and Medicare contractors.
You have 60 days from the date of the Level 2 decision to request an ALJ hearing. You can request this hearing be conducted by video conference, telephone, or in person. ALJs must issue decisions within 90 days, though this timeframe is sometimes extended due to OMHA's backlog. You can represent yourself or have an attorney or non-attorney representative assist you.
Level 4: Medicare Appeals Council Review - If you disagree with the ALJ decision, you can request review by the Medicare Appeals Council, part of the Departmental Appeals Board within the U.S. Department of Health and Human Services. The Council can review ALJ decisions, dismiss appeals, adopt ALJ decisions, or conduct its own review.
You have 60 days from receiving the ALJ decision to request Council review. The Council generally issues decisions within 90 days but may take longer depending on case complexity and workload.
Level 5: Federal District Court Judicial Review - The final appeal level is filing a lawsuit in federal district court. This option is available only if the dollar amount in controversy meets the threshold ($1,900 for 2025) and you've completed all previous appeal levels.
You have 60 days from receiving the Appeals Council decision to file in federal court. Federal court cases can take months or years to resolve and typically require legal representation given their complexity.
Special Rules for Medicare Advantage Appeals
Medicare Advantage plans have some unique appeal procedures. For service denials, plans must provide written notice within specific timeframes depending on whether it's a pre-service or post-service decision. For 2025, Medicare Advantage enrollees have 65 days to file appeals, an extension from the previous 60-day deadline that provides beneficiaries slightly more time to gather information and file their appeals.
Plans overturn their own denials approximately 82% of the time at Level 1 reconsideration, meaning four out of five appeals succeed right at the first level. This high overturn rate suggests many initial denials aren't thoroughly reviewed, making it crucial to appeal even if the denial seems definitive.
Medicare Advantage plans must offer expedited appeals when the standard timeframe could seriously jeopardize your life, health, or ability to regain maximum function. Expedited appeals must be decided within 72 hours. Your doctor can request expedited review on your behalf by certifying that the fast appeal is medically necessary.
For Part D prescription drug appeals, if your plan denies coverage for a drug you haven't yet received, you can request an exception to the plan's formulary or coverage rules. If your doctor supports your request with a statement about medical necessity, the plan must respond within 72 hours or 24 hours for expedited requests. These exception procedures provide an important pathway to get non-formulary drugs covered.
How to File a Successful Appeal
Successfully appealing requires careful preparation and attention to detail. Start immediately—don't wait until near the deadline. Gather all relevant documentation including the denial notice, medical records supporting the service was medically necessary, a statement from your doctor explaining why the service was needed, evidence that Medicare or your plan covers the service under their rules, and any other supporting documentation.
Write a clear, concise appeal letter explaining why you disagree with the denial and why the service should be covered. Reference Medicare coverage rules or your plan's coverage policies that support your position. Include copies (not originals) of all supporting documentation. Keep copies of everything you submit for your records.
Submit your appeal using the method specified in your denial notice, typically by mail to a specific address. Some plans also accept appeals by fax or online portal. Send appeals by certified mail with return receipt requested so you have proof of timely filing. Track all deadlines carefully in a calendar—missing even one deadline can end your appeal rights for that claim.
Consider getting help from professionals. State Health Insurance Assistance Programs (SHIP) provide free assistance with Medicare appeals. Call 1-800-MEDICARE to find your local SHIP. Medicare Advocacy organizations also provide assistance. For large dollar amounts or complex cases, consider hiring a healthcare attorney or professional patient advocate with Medicare appeals experience.
If you need care urgently while appealing, ask your doctor if there are alternative services covered by Medicare or your plan that could meet your immediate needs while the appeal proceeds. Some providers may agree to provide services while awaiting appeal decisions, particularly if they're confident the appeal will succeed.
Getting Help with Medicare Issues
You don't have to navigate Medicare rights and appeals alone. Multiple resources provide free, expert assistance. State Health Insurance Assistance Programs (SHIP) offer free, unbiased counseling and assistance from trained volunteers. SHIP counselors can explain your Medicare rights, help you understand denial notices, assist with filing appeals, and provide guidance throughout the appeals process. Find your local SHIP at shiphelp.org or by calling 1-800-MEDICARE.
Medicare Rights Center (1-800-333-4114) provides national helpline services with information about Medicare rights, coverage, and appeals. Center for Medicare Advocacy offers information and resources about Medicare appeals and advocacy. Local Legal Services and Legal Aid organizations may provide free legal assistance for Medicare appeals, particularly for low-income beneficiaries.
The Medicare Ombudsman helps resolve complaints about Medicare claims processing, appeals, and grievances. Contact the ombudsman through Medicare.gov or by calling 1-800-MEDICARE. 1-800-MEDICARE (1-800-633-4227) provides 24/7 access to Medicare information, including appeals assistance.
Don't hesitate to seek help early in the process. Appeals are most successful when beneficiaries get expert guidance from the beginning. Many denials can be overturned, particularly at lower appeal levels, with proper documentation and presentation.
Understanding your Medicare rights and the appeals process empowers you to advocate effectively for your healthcare. When you believe a denial is wrong, don't accept it as final—exercise your right to appeal. The appeals system exists to protect beneficiaries and correct erroneous decisions. With persistence and proper documentation, many denied claims can be successfully overturned, ensuring you receive the coverage and care you deserve.