What steps do I need to take to appeal a denied Medicare claim?

If you disagree with a coverage or payment decision made by Medicare, you have the right to appeal. While the outcome is not guaranteed, many appeals are successful, so it may be worth your time to appeal.

Before starting the formal appeals process, consider speaking with your doctor, hospital and Medicare representative to see if the issue can be resolved. Many denials are the result of simple billing code errors by the doctor’s office or hospital. If that does not fix the problem, here is how you appeal.

Original Medicare Appeals

If you have original Medicare, review your quarterly Medicare Summary Notice (MSN). This statement lists all the services, supplies and equipment billed to Medicare for your medical treatment and explains why a claim was denied. You can also check your Medicare claims early online at Medicare.gov/providers-services/claims-appeals-complaints/claims/check-status, or by calling Medicare at 1-800-633-4227.

There are five levels of appeals for original Medicare, although you can initiate a “fast appeal” if you are receiving services from a hospital, skilled nursing facility, home health agency, outpatient rehabilitation facility or hospice and the service is ending.

You have 120 days after receiving the MSN to request a “redetermination” by a Medicare contractor, who reviews the claim. Circle the items you are disputing on the MSN, provide a written explanation of why you believe the denial should be reversed and include any supporting documents like a letter from the doctor or hospital explaining why the charge should be covered. Then send the appeal to the address on the form.

You can also file an appeal using the Medicare Redetermination Form. Visit CMS.gov/Medicare/CMS-Forms/CMS-Forms/downloads/CMS20027.pdf to download the form or call 800-633-4227 to request a copy by mail.

The contractor will usually decide your appeal within 60 days after receiving your request. If your request is denied, you can request for “reconsideration” from a different claims reviewer and submit additional evidence.

A denial at this level ends the matter, unless the charges in dispute meet a minimum amount. In 2025, the threshold amount is $190. At this level, you can request a hearing with an administrative law judge. The hearing is usually held by videoconference or teleconference.

If you go to the next level, you appeal to the Medicare Appeals Council. The final level of appeals is judicial review in U.S. District Court. In 2025, the minimum amount in controversy for court review is $1,900.

Advantage and Part D Appeals

If you are enrolled in a Medicare Advantage health plan or Part D prescription drug plan the appeals process is slightly different. With these plans, you have only 65 days to initiate an appeal. In both cases, you must start by appealing directly to the private insurance plan, rather than to Medicare.

If you think that your plan’s refusal is jeopardizing your health, you can ask for an expedited request. A Part D insurer must respond within 24 hours of the request, and a Medicare Advantage health plan must provide an answer within 72 hours.

If you disagree with your plan’s decision, you can file an appeal, which like original Medicare, has five levels. If you disagree with a decision made at any level, you can appeal to the next level.

For more information, along with step-by-step procedures on how to appeal Medicare, go to Medicare.gov/claims-appeals and click on “File an appeal” under the “Appeals” section. It is important to make sure to keep photocopies and records of all communication with Medicare, whether written or oral, concerning your denial.

Need Help?

If you need help filing an appeal, you can appoint a representative (a relative, friend, advocate, attorney or someone else you trust) to help you. Alternatively, contact your State Health Insurance Assistance Program (SHIP), which has counselors that can file your appeal for you for free. To locate your local SHIP, go to ShipHelp.org or call 877-839-2675.

Savvy Living is written by Jim Miller, a regular contributor to the NBC Today Show and author of "The Savvy Living” book. Any links in this article are offered as a service and there is no endorsement of any product. These articles are offered as a helpful and informative service to our friends and may not always reflect this organization’s official position on some topics. Jim invites you to send your senior questions to: Savvy Living, P.O. Box 5443, Norman, OK 73070.