Medicare Appeals · Your Right to a Second Look
Plain English. Five calm steps. No pressure.
If Medicare or your plan says no to a service, a drug or a payment — or says your care should end — you have the right to ask for another decision. Many appeals succeed. Here's how the process works, step by step, and how to meet every deadline.
Free · Private · About a 12-minute read
Your Appeals Path
Read them in order, or jump straight to what you need.
What you can appeal, and the notices to watch for.
Leaving the hospital or care ending? Act fast.
See every level and your first deadline.
What to include, and how to send it.
Who can help you, at no cost.
Step 1 Appeal Basics
When You Can Ask for Another Look
An appeal asks Medicare or your plan to change a coverage or payment decision. You can appeal if:
The notices that start the clock:
For Original Medicare. Mailed every 4 months, listing claims and what Medicare paid. It explains how to appeal any denied item.
Original Medicare
From your Medicare Advantage plan, when it denies care or payment. It tells you why and how to appeal.
Medicare Advantage
Your drug plan's decision on a prescription. If the pharmacy can't fill it, ask for this decision first.
Part D
Appeal or complaint? An appeal is about coverage or payment. A grievance is a complaint about quality or service — like long waits or a rude staff member. You file a grievance with your plan. Concerns about the quality of care can also go to your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO).
Asked to sign an Advance Beneficiary Notice (ABN)? It means your provider expects Original Medicare may not pay. If you choose to get the service, pick the option that asks the provider to bill Medicare — that keeps your right to appeal.
Step 2 Urgent Appeals
When Hours Matter, Not Weeks
Medicare has special fast-track appeals when care is ending or waiting could harm your health. The deadlines are short — call right away.
You'll get a notice called "An Important Message from Medicare." Call the BFCC-QIO number on it no later than your planned discharge day, before you leave. You can usually stay while they decide, without paying for the extra days if you lose.
Call before you leaveYou'll get a "Notice of Medicare Non-Coverage" at least 2 days before services end. Call the BFCC-QIO on the notice by noon the day before services are set to end.
By noon, day beforeAsk your Medicare Advantage plan for an expedited (fast) decision. If your doctor says waiting could seriously harm your health, the plan generally must decide within 72 hours.
About 72 hoursAsk your drug plan for an expedited coverage decision. If you qualify, the plan generally must decide within 24 hours — and within 72 hours on a fast appeal.
24–72 hoursAdmitted, then changed to "observation"? If the hospital changes your status from inpatient to outpatient observation, you may now have the right to appeal that change — which can matter for skilled nursing coverage afterward. Ask the hospital for your notice and call the BFCC-QIO.
Step 3 Your Appeal Path
Five Levels, One at a Time
Choose your type of coverage. Add the date on your notice to see your first deadline as a real date. Most people only need the first level or two.
Deadlines shown are the usual time limits. Your notice may give different dates — always follow your notice. If you miss a deadline, you can ask for an extension and explain why ("good cause"). Dollar amounts in 2026: $200 for a judge's hearing, $1,960 for federal court; they're updated yearly.
Step 4 File a Strong Appeal
Clear, Complete and On Time
Find the reason for the denial, the deadline, and where to send your appeal. Circle them.
A letter from your doctor explaining why the care or drug is medically necessary is often the strongest part of an appeal.
Use the form named on your notice, or write a letter. Include your name, Medicare number, the item denied and why you disagree.
CMS-20027 — Redetermination Request (Level 1)
CMS-20033 — Reconsideration Request (Level 2)
Medicare Advantage and Part D plans have their own forms — your denial notice will say which.
A family member, friend, lawyer or doctor can act for you. Use Form CMS-1696, Appointment of Representative, or a written statement with the same information.
Keep a simple appeal file:
Step 5 Get Free Help
You Don't Have to Do This Alone
Free, unbiased, one-on-one counseling. SHIP counselors can help you understand a denial and prepare an appeal. Find yours at shiphelp.org.
Free · UnbiasedCall 1-800-633-4227 (TTY 1-877-486-2048), 24 hours a day, for help understanding your notice and next steps.
24/7The independent reviewer for fast hospital-discharge and care-ending appeals, and for quality-of-care concerns. The phone number is on your notice.
Urgent appealsMany offices handle appeals and prior authorizations often. Ask whether they can help or send a supporting letter.
Ask themPlan keeps saying no? If your plan's rules don't fit your care, you can choose a different plan during Open Enrollment (October 15 – December 7), or sooner if you have a Special Enrollment Period.
Networks, referrals and prior approval. Medicare Advantage guide →
Drug lists, tiers and exceptions. Drug coverage guide →
How to dispute a penalty. Penalty guide →
Second opinions come first — including on Medicare's decisions.
Common Questions
For Original Medicare, generally 120 days from the date you get your Medicare Summary Notice. For Medicare Advantage and Part D plans, generally 65 days from the date on the denial notice. Urgent appeals — like leaving the hospital — have much shorter deadlines. Always check your notice.
No. There's no fee to file a Medicare appeal at any level. Free help is available from your State Health Insurance Assistance Program (SHIP) and 1-800-MEDICARE.
Five: a first review, an independent review, a hearing before an Administrative Law Judge, a review by the Medicare Appeals Council, and federal court. Dollar minimums apply at the hearing ($200 in 2026) and federal court ($1,960 in 2026) levels.
Call the BFCC-QIO listed on "An Important Message from Medicare" no later than your planned discharge day, before you leave. You can generally stay while they review, and you won't be charged for those extra days if the decision goes against you.
Yes. A family member, friend, doctor or lawyer can represent you. Use Form CMS-1696, Appointment of Representative, or a signed statement with the same information.
You can still ask for an extension. Explain in writing why you were late — for example, a serious illness. This is called showing "good cause."
Still have a question? Just ask.
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