What happens when you appeal a Medicare denial

When Medicare denies a claim, you have the right to challenge that decision through a formal process called an appeal. The appeal does not automatically overturn the denial — you will need to provide new information, correct an error, or show that Medicare misapplied its own rules. Most appeals are decided by the same organization that made the original denial, though you can escalate to an independent reviewer if you disagree with that decision.

The appeal process has five levels, and most people resolve their case at level one or two without going to a hearing. The key to winning is understanding what Medicare says was wrong with your claim and gathering evidence that directly addresses that reason.

Key Takeaways

  • You have 120 days from the date on your denial letter to file a level one appeal, called a redetermination.
  • Your appeal must include new information, a factual error correction, or an explanation of why Medicare misread its own policy — straightforward disagreeing with the decision is not enough.
  • The denial letter states the specific reason Medicare rejected your claim; your appeal should address that reason directly rather than arguing a different point.
  • If your claim is for a service or item that costs more than $200, you can request an independent review at level two instead of waiting for Medicare's internal review.
  • You can represent yourself, have a family member help you, or hire a Medicare advocate or attorney to file and argue your appeal.

Understanding the reason for your denial

Your denial letter from Medicare includes a specific reason the claim was rejected. Common reasons include: the service was not medically necessary, the provider was not in-network, the service is not covered under your plan, you have not met your deductible, or the provider billed incorrectly. The letter also tells you which Medicare contractor made the decision — this is important because you will file your appeal with the same organization.

Read the denial letter carefully and identify the exact reason given. If Medicare says a service was not medically necessary, your appeal should focus on medical evidence that it was. If Medicare says the service is not covered, your appeal should show that it is covered under your specific plan or under Medicare rules. Appealing a different reason than the one stated in the letter wastes time and usually fails.

If the denial letter is unclear or does not give a specific reason, call the Medicare contractor listed on the letter and ask them to explain. Write down the name of the person you speak with, the date, and what they said. This information can strengthen your appeal.

Gathering evidence before you file

The strongest appeals include medical records, provider statements, or documentation that directly contradicts Medicare's reason for denial. If Medicare said a service was not medically necessary, gather notes from your doctor explaining why it was needed. If Medicare said a provider was out-of-network, get a letter from the provider or your plan showing they were in-network. If Medicare said you have not met your deductible, request an itemized statement of what you have paid toward it.

Ask your doctor's office or the provider who gave you the service to help. Many providers have staff who handle appeals and know what evidence Medicare needs. They may have already documented the medical reason for the service in your chart. If the provider billed incorrectly, ask them to correct the bill and resubmit it — this is faster than appealing.

Do not wait to gather evidence after you file your appeal. Medicare gives you only 30 days to submit new information at level one. Collect what you need before you write your appeal letter.

Filing a level one appeal (redetermination)

A level one appeal is called a redetermination. You file it with the same Medicare contractor that made the original denial. You have 120 days from the date on your denial letter to file.

You can file by mail, phone, or online through your Medicare account. The fastest method is usually online through Medicare.gov or your plan's website, because you get a confirmation when ready. If you file by mail, send your appeal to the address listed on the denial letter. If you file by phone, call the number on the letter and ask to speak with someone who handles appeals.

Your appeal letter should be short and direct. State that you are appealing the denial, name the date of service and the claim number, and explain why the denial was wrong. Attach copies (not originals) of your evidence. Do not send the original medical records — Medicare will request them if needed. Keep a copy of everything you send and note the date you sent it.

Medicare has 30 days to make a decision on a redetermination. In practice, many take longer. You will receive a written decision letter in the mail.

When to request an independent review instead

If your claim is for a service or item that costs more than $200, you have the option to skip Medicare's internal review and go straight to an independent reviewer at level two. This is called a reconsideration. The independent reviewer is not employed by Medicare and may be more likely to overturn a denial that Medicare made.

You can request a reconsideration instead of a redetermination, or you can file a redetermination first and then request a reconsideration if Medicare denies it again. If you choose to go straight to reconsideration, you still have 120 days from the denial letter to file. The independent reviewer has 60 days to decide.

Reconsiderations are useful when you believe Medicare misapplied its own policy or when new medical evidence has come to light since the original denial. They are less useful if the issue is a straightforward billing error, which Medicare's internal staff can fix faster.

What to do if your first appeal is denied

If Medicare denies your redetermination, you receive a new letter explaining the decision. You then have the right to file a level two appeal. At this level, an independent reviewer (not employed by Medicare) will look at your case again. You have 180 days from the redetermination denial letter to file.

A level two appeal works best when you have new evidence that was not in your first appeal, or when you believe the first reviewer misunderstood your medical records. If you are straightforward re-arguing the same points with the same evidence, a level two appeal is unlikely to succeed.

If the amount in dispute is less than $200, you cannot file a level two appeal. Your only option is to accept the denial or consult with a Medicare advocate or attorney about whether a higher-level appeal is worth pursuing.

Getting help with your appeal

You can file an appeal on your own, but you can also have someone else help you. A family member, friend, or caregiver can information you in gathering evidence and writing your appeal letter. If you want someone to represent you officially, you can authorize them by signing a form that Medicare provides.

A Medicare advocate is a trained counselor who helps people understand Medicare and file appeals. Many are free through programs like the State Health Insurance information Program (SHIP), which operates in every state. You can find your state's SHIP by calling 1-800-MEDICARE or visiting shiptalk.org. SHIP counselors do not charge a fee.

An attorney or other representative can also file your appeal, but they may charge a fee. If your case involves a large amount of money or complex medical issues, paying for representation may be worth it. Medicare has rules about what representatives can charge, and they must be authorized before they can act on your behalf.

Frequently Asked Questions

What if I miss the 120-day important date to file my appeal?

You cannot file a standard appeal after 120 days. However, you can ask Medicare for a late appeal if you have a good reason for missing the important date, such as serious illness or a postal delay. Submit your request in writing to the Medicare contractor listed on your denial letter, explaining why you missed the important date. Medicare will decide whether to accept your late appeal.

Can I appeal while I am still receiving the service?

Yes. You do not have to wait until the service is finished to appeal. In fact, appealing early can sometimes stop you from receiving bills for services Medicare may not cover. Tell your provider that you have filed an appeal so they know not to bill you while the appeal is pending.

What happens if I win my appeal?

If your appeal is successful, Medicare will pay the claim according to your plan's rules. If you already paid out of pocket, Medicare will send you a refund. If your provider already billed you, contact them to let them know the appeal was approved and ask them to adjust your bill or issue a refund.

Do I have to pay anything while my appeal is pending?

No. While your appeal is being reviewed, you should not receive a bill from your provider for the service in question. If you do receive a bill, contact your provider and tell them an appeal is pending. If they continue to bill you, contact Medicare or your plan to report it.

What if the same claim gets denied again at level two?

You can file a level three appeal with an administrative law judge if the amount in dispute is at least $200. This requires more formal procedures and is usually handled by an attorney. If the amount is less than $200, you have exhausted your appeal rights unless you can show Medicare made a legal error.