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What Is the Medicare Appeals System?

The Medicare appeals system is a five-step process that begins with a request for review, and progresses through administrative channels to federal court, if necessary.

  1. Original Medicare

    • The fee-for-service appeals system starts with a written request for redetermination to the Medicare contractor. This must be done within 120 days of the denial.

      If the beneficiary remains dissatisfied, a written request for reconsideration from the Qualified Independent Contractor (QIC) can be made within 180 days of the redetermination.

    Medicare Advantage

    • Medicare Advantage beneficiaries can request a standard or expedited review of benefit denials within 60 days of the plan's decision. The request is addressed to the plan, and expedited review requests can be oral.

      If the plan upholds its decision, the file is automatically sent to the Part C Independent Review Entity (IRE) for review.

    Part D Process

    • Part D beneficiaries may appeal adverse decisions by requesting a redetermination from the plan. Expedited review requests may be oral; the plan sets the form of standard requests.

      The next step in Part D is a written request (within 60 days of the redetermination) that the Independent Review Entity (IRE) reconsider the decision.

    Administrative Law Judge

    • Regardless of whether the appeal relates to original Medicare, Medicare Advantage or Part D, beneficiaries may request an administrative law judge (ALJ) hearing within 60 days if the amount remaining in controversy meets the threshold for ALJ appeals ($130 in 2010).

    Medicare Appeals Council

    • Beneficiaries who are dissatisfied with an ALJ's decision have 60 days to file a written request for review by the Medicare Appeals Council.

    Judicial Review

    • The final step in the Medicare appeals system is a request for judicial review in federal district court. This must be done within 60 days, and the amount remaining in controversy must meet the threshold ($1,220 in 2010).

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