Medicare appeal levels

You lost the first appeal and the letter says you can go further. What it does not say on its face is whether going further is something you have to do, or something that has already been done for you. On one kind of Medicare it is already done.

What are the Medicare appeal levels?

Medicare has five levels of appeal and they are the same five whichever kind of Medicare you have. Level one is a first look by the plan or contractor. Levels two through five are decided by people outside it, ending in a federal court.

The five run in a fixed order. A redetermination or plan reconsideration, then a reconsideration by an independent contractor, then a decision by the Office of Medicare Hearings and Appeals, then a review by the Medicare Appeals Council, then judicial review in a federal district court.

If you disagree with the decision at any level you can usually go to the next one. That word usually is doing work, and the rest of this page is mostly about what sits behind it.

Every level ends the same way. You get a decision letter, and that letter contains the instructions for moving to the next level. The instruction sheet for step three is inside the answer to step two, which is why the letters matter more than any general guide.

The names change between the two systems at the bottom and converge at the top. Original Medicare calls level one a redetermination and level two a reconsideration by a Qualified Independent Contractor. A Medicare Advantage plan calls level one a health plan reconsideration and sends level two to an Independent Review Entity. From level three up, both systems are in the same rooms.

What happens at each level?

Each level hands your case to a new decision maker. A contractor reviews it first, then an independent contractor, then an administrative law judge, then the Medicare Appeals Council, then a federal district court. At every level you get a letter telling you how to go further.

At level one in Original Medicare, the review is done by staff at the Medicare Administrative Contractor who were not involved in the original decision on your claim. It is the same organization, and deliberately not the same people.

At level two the organization changes. A Qualified Independent Contractor is an independent contractor that took no part in the level one decision. In a Medicare Advantage plan the equivalent body is an Independent Review Entity, and the plan sends its own decision there.

Level three is the first time a person hears you rather than reads you. You can ask for a hearing before an Administrative Law Judge, usually held by phone or video teleconference, and in person if the judge finds you have a good reason. You can also ask for a decision on the record, without a hearing at all.

Level three is the first time a person hears you rather than reads you.

Level four is a review by the Medicare Appeals Council, which looks at what the judge did. Level five moves out of Medicare altogether and into a federal district court, and it is the last level in the process.

What are the deadlines at each appeal level?

In Original Medicare you have 180 days to move from level one to level two, and 60 days at every step after that. In a Medicare Advantage plan you do not file level two at all, because the plan forwards its own refusal automatically.

The ladder is not one ladder. This is our reading rather than a rule either page states, and two government facts produce it.

Medicare.gov says that in Original Medicare you have 180 days after you get the contractor's decision letter or a Medicare Summary Notice to ask for a level two reconsideration. It separately says that when a Medicare Advantage plan decides against you, fully or partially, your appeal is automatically sent to level two.

So one reader has a duty and a clock, and the other has neither, and the list of five levels looks identical from the outside. Those two facts are Medicare's. Reading them as one is ours.

Here is the Original Medicare ladder, step by step.

The level	Who decides it	Your deadline to move up
Level 1 redetermination	A Medicare Administrative Contractor	180 days to ask for level 2
Level 2 reconsideration	A Qualified Independent Contractor	60 days from its decision
Level 3 hearing	An Administrative Law Judge at OMHA	60 days after you get the decision
Level 4 review	The Medicare Appeals Council	60 days after you get the decision
Level 5 court	A federal district court	The last level in the process

Only the first row is unusual. Every step above level one runs on the same 60 days, and the one that does not is the one you are most likely to be standing on.

In a Medicare Advantage plan the top of the table is the same and the bottom is not. You have 60 days from the date of the Independent Review Entity's decision to ask for level three, and nothing to file before that.

When does a judge get involved?

A judge enters at level three, and only if your case is large enough. To reach the Office of Medicare Hearings and Appeals the amount of your case must meet a minimum, and for 2026 that minimum is 200 dollars. Cases under it cannot be filed there.

The gate appears again at the top. To get judicial review in a federal district court the amount of your case must also meet a minimum, and for 2026 that minimum is 1,960 dollars. You may be able to combine claims to reach either figure.

Both numbers change from year to year, so the figure printed in an old article is not the figure that applies to you. The ones above are the amounts for 2026.

Read against the bottom of the ladder, those two gates describe the shape of the whole process. CMS states that no minimum monetary threshold is required to request a redetermination. So the first appeal is open to any claim of any size, and the levels that involve a judge are not.

What a hearing actually is, is worth knowing before the word judge does too much work. An Administrative Law Judge hearing lets you present your appeal to a new person who reviews the facts independently and listens to your testimony. It is usually held by phone or by video teleconference.

You can also decline the hearing. In certain circumstances you can ask for an on the record review by a judge or an attorney adjudicator, decided only on what is already in your appeal file.

What are my odds of winning?

Medicare does not publish your odds. None of the government pages behind this article states a win rate at any level. What they do describe is the structure: a different decision maker each time, and the right to send in information that was not there before.

That absence is worth naming plainly, because the figures in circulation are not measuring what a reader assumes. A percentage drawn from prior authorization decisions inside Medicare Advantage plans is not the chance that your claim appeal succeeds, and this publication does not carry a number it cannot source to a government page.

CMS does publish data on redeterminations, in fact sheets on its own appeals page. Those files were not opened for this article, so nothing is claimed here about what they contain.

What is knowable is what changes between levels, and two things do. The first is who is looking. At level one in Original Medicare it is contractor staff not involved in the original decision. At level two it is an organization that took no part in level one. At level three it is a judge.

The second is what they are looking at. Both appeal request lists invite you to include any other information that may help your case, such as a note from your doctor, and Medicare's instruction before you start anything is to ask your provider or supplier for information that makes the appeal stronger. A later level is not only a fresh reader. It can be a fuller file.

Do I need a lawyer?

Nothing in Medicare's own appeal instructions requires a lawyer. The helper those pages name is a representative, which can be a trusted family member or friend, and appointing one takes a form. Free counseling is also available from your State Health Insurance Assistance Program.

That is an absence rather than a permission, and it is worth being exact about the difference. No page read for this article says you must have a lawyer, and none says you must not have one. What they set out is a process built to be used without one.

The representative is a formal role rather than an informal helper. Both appeal request lists ask for the representative's name and for proof of representation, and Original Medicare asks for a copy of the Appointment of Representative form or another written instrument with the required elements. A contractor may dismiss a request where a representative was not appointed properly.

The State Health Insurance Assistance Program is the free option. SHIPs are state programs that get money from the federal government to give free local health insurance counseling to people with Medicare, and personalized counseling costs nothing.

The hearing itself is not built to be intimidating. It is usually held by phone or video teleconference, and it exists so a new person can hear the facts and your testimony rather than only read the file. In person hearings happen where the judge finds a good reason for one.

What this means for you

Five levels, one fixed order, and two very different journeys through them. What changes is not the staircase itself but who is expected to take the next step, and that difference is invisible from any list of the five levels.

In Original Medicare every step is yours to file. Level one to level two is 180 days, and each step above that is 60. In a Medicare Advantage plan the plan sends its own refusal upward for you, and your first deadline arrives after level two rather than before it.

Money decides how far the ladder goes. There is no minimum to ask for a redetermination, and there is one to reach a judge: 200 dollars in 2026 for a hearing, and 1,960 dollars in 2026 for a federal court. Claims can sometimes be combined to reach either.

Nobody publishes your odds. What is published is that each level brings a new decision maker and that you may add information at each one, which is the only part of the outcome you control.

For how to file the first appeal and the deadline for getting it in, read this publication's article on how to appeal a Medicare denial. If the problem is service rather than coverage, the article on filing a complaint about a Medicare plan explains a different route entirely.

FAQ

Are the five levels the same for Original Medicare and a Medicare Advantage plan?

The five levels are the same and the first two have different names and different mechanics. In Original Medicare, level one is a redetermination by a Medicare Administrative Contractor and level two is a reconsideration by a Qualified Independent Contractor that you must request yourself within 180 days.

In a Medicare Advantage plan, level one is a health plan reconsideration decided by the plan, and if the plan decides against you fully or partially, it forwards its decision to an Independent Review Entity automatically.

From level three upward the two systems merge: the Office of Medicare Hearings and Appeals, then the Medicare Appeals Council, then a federal district court.

What is the deadline to move from one level to the next?

In Original Medicare, you have 180 days after you get the contractor's decision letter or a Medicare Summary Notice to ask for level two. After that the pattern settles into 60 days at every step.

It is 60 days from the date of the level two decision to ask for level three, 60 days after you get the level three decision to ask for a Medicare Appeals Council review, and 60 days after you get the Council's decision to ask for judicial review.

In a Medicare Advantage plan the first of those disappears, because level two is forwarded for you, and your deadline is 60 days from the date of the Independent Review Entity's decision.

Why does my case need to be worth a certain amount?

Two levels have a minimum amount in controversy and the rest do not. To file at the Office of Medicare Hearings and Appeals the amount of your case must meet a minimum, which is 200 dollars in 2026.

To get judicial review in a federal district court the minimum is 1,960 dollars in 2026. You may be able to combine claims to reach either figure. Both amounts are set for the year and change, so a figure quoted in an older article is not the one that applies to you.

At the other end of the ladder there is no threshold at all: CMS states that a minimum monetary threshold on the claim is not required to request a redetermination.

What actually happens at an Administrative Law Judge hearing?

It is the first level where someone hears you rather than reads you. A hearing before an Administrative Law Judge lets you present your appeal to a new person who independently reviews the facts and listens to your testimony before deciding.

It is usually held by telephone or by video teleconference, and it can be held in person if the judge finds that you have a good reason. You do not have to have a hearing at all.

In certain circumstances you can ask for an on the record review by a judge or an attorney adjudicator, which is a decision made only on what is already in your appeal file.

Can I add new evidence as I go up the levels?

The appeal request lists invite it. Both the Original Medicare and the Medicare Advantage lists ask you to include any other information that may help your case, and both name a note from your doctor as an example.

Medicare's own instruction before you start any appeal is to ask your provider or supplier for information that will make the appeal stronger, which suggests the file you send is not fixed at the moment of the first refusal.

That matters because each level is a genuinely new decision maker rather than the same person reading the same page again, so what they see can change as well as who they are.

Who can help me if I do not want to do this alone?

Two routes, and neither is a lawyer. You can appoint a representative, and Medicare describes that person as a trusted family member or friend.

The role is formal, though. The appeal request must carry the representative's name and proof of representation, and Original Medicare asks for a copy of the Appointment of Representative form or another written instrument with the required elements.

Getting that wrong has a consequence, because a contractor may dismiss a request where the representative was not properly appointed. The second route is your State Health Insurance Assistance Program, a state program funded by the federal government that gives free local counseling to people with Medicare.