Medicare, the five levels

Appeal Medicare denial: the five levels, and the date each one is due

To appeal a Medicare denial, ask for a redetermination within 120 days of getting your Medicare Summary Notice; CMS presumes that is 5 days after its date.

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By Axion Labs · published October 14, 2026

Appeal Medicare claim denial: the five levels in Original Medicare

Original Medicare is Part A and Part B. There are 5 levels of appeal. If you disagree with the decision at one level, you can usually go to the next, and each decision letter tells you how. This is the order Medicare.gov sets out, read October 14, 2026:

Level	What it is called	Who decides	Your deadline	Dollar minimum	How fast they answer
1	Redetermination	The Medicare Administrative Contractor named on your Medicare Summary Notice	120 days from the day you get the notice (presumed 5 days after its date)	None	Generally within 60 days
2	Reconsideration	A Qualified Independent Contractor that took no part in level 1	180 days after you get the redetermination letter	None	Within 60 days after it gets your request
3	Hearing, or a decision on the record	The Office of Medicare Hearings and Appeals: an Administrative Law Judge or attorney adjudicator	60 days from the date of the reconsideration decision	$200 for 2026	Not stated on the page
4	Appeals Council review	The Medicare Appeals Council	60 days after you get the hearing decision	None stated	Not stated on the page
5	Judicial review	A federal district court	60 days after you get the Appeals Council decision	$1,960 for 2026; claims may be combined	Not stated on the page

The level 1 clock is CMS’s: the redetermination page (page last modified March 10, 2026) gives 120 days from receipt of the notice, and presumes receipt 5 days after its date. The rule behind it is 42 CFR 405.942 (govinfo copy). The 2026 minimums are the ones Medicare.gov prints for this year; they change each year, and Medicare.gov is where the new figure appears.

How long to appeal a Medicare denial

120 days for the first level. Then 180 days to ask for a reconsideration. Then 60 days at each of the last three levels. Medicare.gov says you must file the first appeal by the date in your Medicare Summary Notice, so read that date first; it governs.

A late appeal is not always lost. Medicare.gov says you may still get a decision if you show good cause for missing the deadline, for example a disability, illness or accident that delayed you. Under 42 CFR 405.942 a request counts as filed on the day the contractor receives it, so send it early and keep proof of the date.

How to appeal Medicare denial of payment, step by step

Find the claim on your Medicare Summary Notice. Circle the item or service you disagree with on a copy.
Say why it should be covered. Use form CMS-20027, or a letter with your name, address, Medicare Number, the items and dates, and the reason.
Add what helps. A note from your doctor and the records behind it. Ask your provider for anything that supports the claim.
Send it to the Medicare Administrative Contractor at the address on the last page of your notice. Keep a copy and the date you sent it.
If someone files for you, add the appointment of representative form. CMS lists it, and a written notice with the same elements also works.

Steps 1 to 4 are the ones Medicare.gov lists for level 1. The contractor generally answers within 60 days after it gets your appeal.

If you have a Medicare Advantage plan

A Medicare Advantage plan runs its own first level, called a plan reconsideration. You, your representative or your doctor must file within 65 days from the date on the plan’s initial denial notice. The plan answers a pre-service appeal in 30 days, a payment appeal in 60 days and a Part B drug appeal in 7 days, and it can take up to 14 days more in some cases. If waiting could seriously harm your health, ask for a fast appeal: the plan must decide within 72 hours. All of that is from Medicare.gov, read October 14, 2026.

If the plan says no, it sends your case to an Independent Review Entity by itself. That is level 2. After it, you have 60 days to ask for a hearing, and for 2026 the amount in dispute must be at least $200.

If the denial came through WISeR

In the WISeR states, a prior authorization request that comes back non-affirmed is not a denial you can appeal. The claim denial on your Medicare Summary Notice is, on the clock above. Which WISeR deadline you are on, state by state.

Free help, from a person

Your State Health Insurance Assistance Program gives free one-to-one counseling, including on appeals (shiphelp.org). 1-800-MEDICARE answers questions too. Neither costs anything, and this route needs nothing from denialfacts.

Questions

How do I appeal a Medicare denial?

In Original Medicare, start with a redetermination: circle the denied item on a copy of your Medicare Summary Notice, say in writing why it should be covered, and send it, or form CMS-20027, to the contractor at the address on the notice. If that is turned down you can go on, level by level, to a reconsideration, a hearing, the Medicare Appeals Council and a federal court. Each decision letter tells you how to take the next step.

How long do I have to appeal a Medicare denial?

120 days for the first level, counted from the day you get the Medicare Summary Notice; CMS presumes you get it 5 days after its date. Then 180 days to ask for a reconsideration, and 60 days at each of the last three levels. If you miss a deadline, Medicare.gov says you may still get a decision if you show good cause, such as an illness or accident that delayed you.

Is there a minimum amount to appeal a Medicare denial?

Not at the first two levels. For 2026, Medicare.gov puts the minimum at $200 for a hearing at level 3 and $1,960 for a federal court at level 5, and you may be able to combine claims to reach it.

How do I appeal a Medicare Advantage denial?

Ask your plan for a reconsideration within 65 days from the date on its denial notice. If the plan says no again, it sends your case to an Independent Review Entity automatically. From there the route joins the later levels of Original Medicare.

The documents behind this page, and the day each was read

Medicare.gov, Appeals in Original Medicare, read October 14, 2026
Medicare.gov, Appeals in Medicare health plans, read October 14, 2026
CMS, First Level of Appeal: Redetermination by a Medicare Contractor, read October 14, 2026 (page last modified March 10, 2026)
CMS, Original Medicare (Fee-for-service) Appeals, read October 14, 2026 (page last modified August 25, 2026)
42 CFR 405.942, time to request a redetermination (eCFR), read October 14, 2026
42 CFR 405.942, govinfo mirror, read October 14, 2026
Form CMS-20027, Medicare Redetermination Request Form, read October 14, 2026
SHIP, State Health Insurance Assistance Programs, read October 14, 2026

This page describes the Original Medicare and Medicare Advantage appeal processes as Medicare.gov and CMS publish them, read on the dates above. It is not legal or medical advice, and no outcome is guaranteed. Your Medicare Summary Notice and any decision letter govern your case and print your deadlines. Free help: your State Health Insurance Assistance Program, or 1-800-MEDICARE.