The short answer
You appeal a Medicare denial by asking whoever refused to look again, and the deadline depends on which Medicare you have. Original Medicare gives you 120 days from when you received the notice. A Medicare Advantage plan or drug plan gives you 65 days from the date on it.
The letter says no and gives you a date. You look at the date on the notice and start counting from there. That is the wrong day to count from, and on one kind of Medicare it costs you five days you were entitled to.
How do I appeal a Medicare denial?
You appeal by asking whoever refused to look at the decision again. With Original Medicare the request goes in writing to a Medicare Administrative Contractor. With a Medicare Advantage plan or a drug plan it goes to the plan itself, following the directions printed on your denial notice.
An appeal is available for more than a flat refusal. You can file one if Medicare or your plan refuses to cover something you think should be covered, refuses to pay for something you already got, or changes the amount you must pay.
You can also appeal when Medicare or your plan stops providing or paying for something you think you still need. That last one catches people, because nothing was refused. Something that was running simply stopped.
There is one more. If your plan's drug management program labels you as at risk, because you meet the Overutilization Monitoring System criteria, that decision carries appeal rights too.
Before you file anything, ask your provider or supplier for information that may help your case. Medicare puts that step first, before the paperwork, and it is the cheapest thing on this page.
You do not have to do it alone. A trusted family member or friend can be appointed as your representative. Free, personalized counseling is also available from your State Health Insurance Assistance Program, a state program funded by the federal government.
What is the first level of appeal?
The first level has a different name in each system. In Original Medicare it is a redetermination, decided by a Medicare Administrative Contractor whose staff took no part in the original decision. In a Medicare Advantage plan it is a health plan reconsideration, decided by the plan.
That difference in who decides is worth sitting with. In Original Medicare the review is done by people at the contractor who were not involved in the first look at your claim. In a Medicare Advantage plan, level one is the plan reviewing the plan.
In a Medicare Advantage plan the coverage decision you are appealing has a name of its own. It is called an organization determination, and you have the right to one, spoken or written, to find out whether a service, drug or supply is covered.
Who is allowed to file also differs. In a Medicare Advantage plan you, your representative, or your doctor or health care provider may file. If the appeal is for a service you have not had yet, your doctor can ask for the reconsideration on your behalf and must tell you they did.
One rule at this level removes a barrier that appears higher up. There is no minimum dollar amount to request a redetermination. A claim for a small sum gets the same first appeal as a claim for a large one, which is not true at every level of the process.
What is the deadline to file a Medicare appeal?
There is no single deadline. Original Medicare allows 120 days from the date you received the notice, and a notice is presumed received 5 calendar days after the date printed on it. A Medicare Advantage plan and a drug plan each allow 65 days.
The deadline is not the number. It is the starting date. This is our reading rather than a rule any one page states, and three government facts produce it.
CMS says the 120 days runs from the date of receipt, and presumes receipt to be 5 calendar days after the date on the notice unless there is evidence otherwise. Medicare.gov says a Medicare Advantage plan counts 65 days from the date on the initial denial notice. CMS says a drug plan counts 65 calendar days from the date of the coverage determination notice.
So two of the three count from the day the letter was written, and one counts from the day it landed in your hands. Those three facts are the government's. Reading them together is ours.
Here is what applies to what.
| Your kind of Medicare | The deadline to file | When the count starts |
|---|---|---|
| Original Medicare | 120 days | Receipt, presumed 5 calendar days after the notice date |
| Medicare Advantage plan | 65 days | The date printed on the initial denial notice |
| Medicare drug plan | 65 calendar days | The date of the coverage determination notice |
The first row is the one to read twice. Two of these count from the day a notice was dated, and only one counts from the day it reached you.
Miss the date and you are not finished. In Original Medicare you may still file and get a decision if you can show good cause, and Medicare's own examples are a disability, an illness or an accident that delayed you. A Medicare Advantage plan asks you to give a reason for filing late.
What do I need to submit?
Your request names you and it names the claim. Original Medicare wants your name, address and Medicare number, the exact items or services and their dates, and why you think they should be covered. A Medicare Advantage plan wants the same, plus the reasons you are appealing.
In Original Medicare the request must be in writing. CMS gives two ways to do it: fill in form CMS-20027, or send a written request containing all six of these.
- The beneficiary name and the Medicare number
- The specific service or item the redetermination is being requested for
- The specific dates of service
- The name of the party, or the representative of the party
- An explanation of why you disagree with the contractor's determination
Medicare.gov describes the same appeal from the reader's side and adds two things worth including. Circle the items you are appealing on a copy of your Medicare Summary Notice, and send any other information that may help your case, such as a doctor's note.
If you appointed a representative, include a copy of the Appointment of Representative form, or another written instrument that has the required elements.
There is a quiet reason to be careful with all of this. A contractor may dismiss a request where the representative was not appointed properly, or where the person filing is not a proper party. A dismissal is not a decision on your claim, and getting one means starting over on procedure rather than on the merits.
How long does a Medicare appeal take?
Original Medicare generally answers a first level appeal within 60 days. A Medicare Advantage plan runs several clocks instead of one, and which applies depends on what you asked for: 30 days before you get a service, 60 days for a payment, 7 days for a Part B drug.
In Original Medicare the answer arrives in one of two shapes. If the contractor decides Medicare will cover the item, it appears on your next Medicare Summary Notice. If it decides Medicare will not, you get a written decision letter called a Medicare Redetermination Notice.
A Medicare Advantage plan can take longer than its own numbers suggest. The time may be extended by up to 14 days, for instance where the plan needs more information from a provider outside its network and the extension is in your interest. The plan must tell you in writing that it is taking one, why, and what your rights are if you disagree.
There is a faster track inside the plan process. If you think your health could be seriously harmed by waiting the standard 30 days, you can ask for an expedited appeal. The plan must decide within 72 hours if it determines, or your doctor tells it, that waiting may seriously jeopardize your life, your health, or your ability to regain maximum function.
A drug plan runs on its own clocks again: 7 calendar days for a standard request, 72 hours for an expedited one, and 14 calendar days where the request is for payment.
What is a fast appeal?
A fast appeal is the one you file when covered services are ending too soon, not when a claim was refused. It applies to a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility or hospice, and an independent reviewer decides it.
The reviewer is called a Beneficiary and Family Centered Care Quality Improvement Organization. The same organization also handles complaints about the quality of your care, which is a different job under the same name, so meeting the acronym twice is not a sign you have misread something.
Notice that this is a second meaning of the word fast. The expedited appeal in the section above is your plan deciding a coverage request in 72 hours. This one is an outside reviewer deciding whether services already running should continue.
The notice comes to you before the services stop. In a hospital, within 2 days of admission and before discharge, you should receive An Important Message from Medicare about Your Rights. In other settings you should receive a Notice of Medicare Non-Coverage at least 2 days before covered services end. If neither arrives, ask for it.
The deadline is tied to your discharge day rather than to a count of days. In a hospital you follow the directions on the Important Message no later than the day you are scheduled to be discharged. In other settings you follow the notice no later than noon the day before the termination date printed on it.
Asking in time changes who pays while you wait. If you ask within the hospital time frame you can stay while the reviewer decides, and you will not have to pay for the stay beyond applicable coinsurance or deductibles. The reviewer decides within one day of getting the information it asked for, and by close of business the next day in other settings.
Miss it and the door is still open, on worse terms. You can still ask the reviewer to look, but different rules and time frames apply, and you might be responsible for the cost of the stay past the day the hospital first tried to discharge you.
What this means for you
A denial is not one thing. The question that decides everything else is which kind of Medicare sent the letter, because that sets the name of the appeal, who reviews it, how long they have, and the date your window opens.
The number is the easy half. Original Medicare gives 120 days and both kinds of plan give 65, and the harder half is the starting date. Only Original Medicare counts from receipt, and only Original Medicare presumes receipt to be 5 calendar days after the date on the notice.
Level one is free of the money tests that appear higher up. No minimum dollar amount applies to a redetermination, so a small claim gets the same first hearing as a large one.
And the word fast means two different things. One is your plan deciding a request in 72 hours. The other is an outside reviewer deciding whether care that is already running should stop, on a deadline measured to the hour.
For what happens after a refusal at this level, read this publication's article on the Medicare appeal levels. If your problem is the service rather than the coverage, the article on filing a complaint about a Medicare plan is the one you want.
FAQ
Where do I find the deadline for my own appeal?
On the notice that told you no. In Original Medicare that is your Medicare Summary Notice, and Medicare.gov instructs you to file by the date in it.
Behind that instruction sits the rule CMS states: you have 120 days from the date you received the initial claim determination, and the notice is presumed to be received 5 calendar days after the date printed on it, unless there is evidence to the contrary.
In a Medicare Advantage plan the window is 65 days from the date on the initial denial notice your plan sent. A drug plan gives you 65 calendar days from the date of the coverage determination notice. Three systems, three deadlines, and two different events to count from.
What can I actually appeal?
More than a refusal to cover something. You can appeal when Medicare or your plan refuses to cover a service, supply, item or drug you think should be covered, refuses to pay for one you already received, or changes the amount you must pay.
You can also appeal when Medicare or your plan stops providing or paying for all or part of something you think you still need, which is the case where nothing was formally refused and something simply ended.
There is one more that is easy to miss: if your plan's drug management program labels you as at risk because you meet the Overutilization Monitoring System criteria, that decision carries appeal rights as well.
Does it cost anything, and does my claim have to be big enough?
Not at the first level. CMS states plainly that a minimum monetary threshold on the claim is not required to request a redetermination, so the size of the bill does not decide whether you get a first appeal.
That is not true all the way up the process, where dollar minimums do appear and are set each year, but it is true of the level almost every appeal starts at.
Free help is available too. Your State Health Insurance Assistance Program gives personalized counseling at no charge, and you can appoint a trusted family member or friend as your representative to handle the paperwork and speak for you.
What happens if I miss the deadline?
It is not automatically over. In Original Medicare you may still file and get a decision if you can show good cause for missing the deadline, and Medicare's own examples are a disability, an illness or an accident that delayed you from sending it. A Medicare Advantage plan requires you to give a reason for filing late.
Be aware of a separate risk that has nothing to do with lateness: a contractor may dismiss a request for defects, such as a representative who was not appointed properly or a person filing who is not a proper party. A dismissal is not a ruling on your claim, and it has its own routes and its own clocks.
How is a fast appeal different from an expedited one?
They are two different mechanisms wearing the same adjective. An expedited appeal is your Medicare Advantage plan deciding a coverage request within 72 hours instead of the standard 30 days, available when waiting may seriously jeopardize your life, your health, or your ability to regain maximum function.
A fast appeal is what you file when covered services are ending too soon in a hospital, skilled nursing facility, home health agency, comprehensive outpatient rehabilitation facility or hospice. It is decided by an outside reviewer rather than by your plan, and the deadline is measured against your discharge day or noon the day before services end.
If I ask for a fast appeal, who pays while I wait?
In a hospital, ask within the time frame on the Important Message from Medicare and you can stay while the reviewer decides. You will not have to pay for that stay beyond applicable coinsurance or deductibles.
The reviewer makes its decision within one day of getting the information it asked for, and by close of business the following day in other settings.
If you miss the deadline, you can still ask the reviewer to look at your case, but different rules and time frames apply and you might be responsible for the cost of the hospital stay past the day the hospital first tried to discharge you. Missing it narrows the protection rather than removing the review.
