The Five Levels of the Medicare Appeals Process
Original Medicare features five formal appeal levels. If a reviewer rules against you, you can escalate your claim to the next tier.
Level 1: Redetermination by a Medicare Administrative Contractor
Level 1 is a redetermination by a Medicare Administrative Contractor (MAC). The reviewer must not have participated in the initial denial.
Submit your Level 1 appeal within 120 days of the date on your denial notice. Medicare allows a five-day grace period for mail delivery.
The contractor typically issues its written decision within 60 days. If approved, your payment or coverage adjustment processes automatically.
Level 2: Reconsideration by a Qualified Independent Contractor
If the MAC upholds the denial, you advance to Level 2. A Qualified Independent Contractor (QIC) conducts an independent reconsideration of your case.
You have 180 days from receiving the Level 1 decision to file. The QIC assigns healthcare professionals to review your medical records.
Submit all supporting medical documentation and physician letters now. Federal rules restrict introducing new medical evidence during later appeal stages.
Level 3: Hearing with an Administrative Law Judge
If the QIC denies your claim, request a Level 3 hearing through the Office of Medicare Hearings and Appeals (OMHA).
Submit your request within 60 days of the Level 2 decision. An Administrative Law Judge (ALJ) or attorney adjudicator examines the case independently.
Your claim must satisfy an Amount in Controversy (AIC) threshold: at least $200 for calendar year 2026, and $200 in 2027.
OMHA generally issues decisions within 90 days. You or your representative may present oral testimony by telephone or video conference.
Level 4: Review by the Medicare Appeals Council
If the judge issues an unfavorable ruling, request a Level 4 review by the Medicare Appeals Council within the Department of Health and Human Services Departmental Appeals Board.
File within 60 days of receiving the judge’s decision. The Council reviews legal and procedural applications rather than holding a new hearing.
Level 5: Judicial Review in Federal District Court
Level 5 is judicial review. You file a civil action in a United States District Court within 60 days of the Council’s decision.
These judicial thresholds adjust over time alongside broader Medicare policy updates and administrative changes established by CMS.
Federal court appeals require a minimum disputed balance of $1,960 for calendar year 2026, increasing to $2,000 on January 1, 2027.
| Appeal Level | Reviewing Entity | Filing Deadline | Minimum Disputed Amount (2026 / 2027) |
|---|---|---|---|
| Level 1 | Medicare Administrative Contractor (MAC) | 120 days from notice date | None |
| Level 2 | Qualified Independent Contractor (QIC) | 180 days from Level 1 decision | None |
| Level 3 | Office of Medicare Hearings and Appeals (OMHA) | 60 days from Level 2 decision | $200 in 2026 / $200 in 2027 |
| Level 4 | Medicare Appeals Council | 60 days from Level 3 decision | None |
| Level 5 | Federal District Court | 60 days from Level 4 decision | $1,960 in 2026 / $2,000 in 2027 |
