How do you appeal a Medicare denial?

Updated October 12, 2026 · General information, not professional advice

First, figure out which kind of Medicare your parent has

The appeal path depends on the coverage:

• Original Medicare (Parts A and B): Denials show up on the Medicare Summary Notice (MSN), mailed at least every 6 months unless you choose electronic notices.
• Medicare Advantage plan: The plan sends its own denial notice.
• Part D drug plan: The plan decides drug coverage and sends its own notice.

Every decision letter explains how to move to the next step. Keep copies of everything and write down who you spoke to and when.

Appealing in Original Medicare

1. Redetermination: File within 120 days of getting the MSN. Use form CMS-20027, or circle the item on a copy of the MSN and explain in writing why it should be covered. A Medicare contractor generally decides within 60 days.
2. Reconsideration: If you still disagree, file within 180 days with a Qualified Independent Contractor, using form CMS-20033. It generally decides within 60 days.
3. Hearing: Within 60 days, ask for a hearing with an Administrative Law Judge (form OMHA-100). In 2026, at least $200 must be in dispute.
4. Medicare Appeals Council review: File within 60 days of the hearing decision.
5. Federal court: File within 60 days. In 2026, at least $1,960 must be in dispute, and claims can sometimes be combined.

A letter from the doctor explaining why the care was medically needed can strengthen the appeal. If you miss a deadline for a good reason, like a serious illness, you can ask for more time.

Medicare Advantage and Part D appeals

• Level 1: Ask the plan to reconsider within 65 days of the date on its denial notice.
• Medicare Advantage timing: The plan generally decides within 30 days for care not yet received, 60 days for a payment request and 7 days for Part B drugs.
• Part D timing: Generally 7 days for a drug you haven't gotten yet and 14 days for a payment request.
• Expedited appeals: If waiting could seriously harm your parent's health, ask for a fast decision. These are generally decided within 72 hours.
• Level 2: An Independent Review Entity reviews the case. A Medicare Advantage plan that keeps its denial sends the case on automatically. For Part D, you file within 60 days.

Levels 3 through 5 work much like Original Medicare. If a plan change might help, see how to help a parent switch Part D plans.

Fast appeals when care is ending

If your parent is being discharged and you think it's too soon, you can ask the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for a fast appeal.

• Hospital: Your parent should get a notice called "An Important Message from Medicare about Your Rights." Call the BFCC-QIO no later than the day of the planned discharge. It generally decides within one day of getting the information it needs.
• Skilled nursing, home health, hospice or an outpatient rehab facility: You should get a "Notice of Medicare Non-Coverage" at least 2 days before services end. Call by noon the day before the end date on the notice.

The phone number is on the notice. Related reading: how many skilled nursing days Medicare covers and the 3-day hospital rule and observation status.

Where to get free help

Your State Health Insurance Assistance Program (SHIP) offers free, one-on-one Medicare counseling, and you can find yours at shiphelp.org. You can also call 1-800-MEDICARE (1-800-633-4227). If a family member will handle the appeal, your parent can name them as a representative with form CMS-1696. Rules for Special Needs Plans, PACE and other plan types can differ, so follow the instructions in your parent's notice.

seniorcare.si can show licensed rehab and skilled nursing near your ZIP code if your parent needs care while an appeal is pending.