The five levels of Medicare appeals in plain words
A Medicare Part A or Part B denial can be appealed through five levels: redetermination, reconsideration, an ALJ hearing, Medicare Appeals Council review and federal court. At each level you file a written request with the office named on the last notice, and the evidence you send early decides what you can use later.
Written by Salman Saeed, CEO and Co-Founder · Reviewed by a Certified Medical Coder · 
In short: find the last notice you hold, because it names the next level and the office to file with. File a redetermination with the MAC in 120 days, then a QIC reconsideration in 180, then 60 days for each later level. Put every document in front of the QIC, because new evidence at the hearing needs a stated reason.
Which level of Medicare appeal are you on?
Look at the last document you received, because it tells you. A remittance advice is the notice of an initial determination, a redetermination notice leads to a reconsideration, and so on up the ladder. The deadlines and amounts for every level are on the Medicare appeal levels rule page, and this post is the working order.
| The last document you hold | The next request | Where it goes |
|---|---|---|
| Remittance advice or initial determination notice | Redetermination | The contractor named on the notice (42 CFR 405.944(a)) |
| Redetermination notice | Reconsideration | The QIC named on the redetermination notice (405.964(a)) |
| QIC reconsideration notice | ALJ hearing | The office named in the reconsideration notice (405.1014(c)(2)) |
| ALJ or attorney adjudicator decision | Council review | The entity named in the decision notice (405.1102(a)(3)) |
| Council decision | Civil action in federal district court | The court. The notice explains how |
Filing with the wrong office is not always fatal. If a hearing request is timely filed with another OMHA office, 405.1014(c)(2) says it is not treated as late, but the clock for a decision starts only when the right office receives it. Send to the named office the first time.
Not every adverse notice has appeal rights. A finding that a submission does not meet the requirements for a Medicare claim is not an initial determination under 42 CFR 405.924(b), so a returned or rejected claim is corrected and resent. A claim denied as untimely is also outside the appeal path; see how to appeal a timely filing denial.
Level 1: What does a redetermination request need?
A redetermination is the first appeal, and the MAC decides it. File within 120 calendar days of receiving the notice, with receipt presumed 5 calendar days after the date on the notice (42 CFR 405.942).
The request must be in writing and should use the standard CMS form. Under 405.944(b) it is accepted without the form if it has the beneficiary's name, the Medicare number, the specific services and dates of service, and the name of the party or its representative. Section 405.946(a) adds that you must explain why you disagree and should include your evidence.
Parties to the initial determination include a provider that filed the claim and a supplier that accepted assignment (405.906(a)). If a representative files for you, the appointment must be in writing, signed and dated by both sides, and include seven elements listed in 405.910(c). CMS offers form CMS-1696 for this, and an appointment is valid for one year from the date both signatures are on it unless it is revoked. File the appointment with the appeal request.
The letter to put on top of the request is covered in how to write a claim appeal letter, and the packet for a medical necessity denial is in how to appeal a CO-50 denial.
Level 2: Why must you put everything in front of the QIC?
Because the QIC is the last stage where you can add evidence without a justification. The QIC reconsideration must be requested within 180 calendar days of receiving the redetermination (405.962). Under 405.966(a), the request should present evidence and explain why you disagree, and it must include any missing documentation named in the redetermination notice.
The redetermination notice is a checklist. Under 405.956(b)(6) to (8), it states any specific missing documentation, says all evidence should go with the reconsideration request, and warns that evidence not submitted to the QIC is not considered at the OMHA level or beyond unless you show good cause. Section 405.966(a)(2) says that, absent good cause, failing to submit all evidence, including documentation requested in the redetermination notice, before the reconsideration is issued precludes considering it later.
The reconsideration request must also have the name of the contractor that made the redetermination (405.964(b)(5)). Each evidence submission after the request extends the QIC's 60 calendar day decision time by up to 14 calendar days (405.966(b)), so file the whole set at once.
Level 3: What changes at the ALJ hearing?
The request is due 60 calendar days from receiving the QIC's reconsideration, and it has more required content. Under 405.1014(a), it must include the Medicare appeal number or document control number from the QIC notice, the dates of service, the reasons you disagree and a statement of any additional evidence to be submitted and the date it will be submitted.
Send a copy of the request to the other parties who were sent the QIC reconsideration (405.1014(d)). The ALJ tells the parties how the hearing will be held; under 405.1020(b)(2) a party that is not an unrepresented beneficiary appears by telephone unless the ALJ finds good cause for another means.
New evidence now has a gate. Section 405.1018(c) says evidence a provider submits that was not submitted before the QIC's decision must come with a statement explaining why it was not sent to the QIC, and without that statement it will not be considered. Section 405.1028(a) lists the good cause grounds, such as being unable to obtain the evidence before the reconsideration despite reasonable attempts, or showing that you did send it to the QIC. The amount in controversy rules for this level are on the rule page.
Levels 4 and 5: How do Council review and federal court work?
Council review is requested within 60 calendar days of receiving the ALJ or attorney adjudicator decision, with receipt presumed 5 calendar days after the notice date (405.1102). Your request must name the parts of the decision you disagree with and explain why (405.1112(b)). Under 405.1112(c), the Council limits its review to the exceptions you raise, unless the appellant is an unrepresented beneficiary.
The Council's decision is final unless a federal district court modifies it or it is revised on reopening, and a civil action must be filed within 60 calendar days after receiving the notice (405.1130). The court level has its own amount in controversy and schedule, covered on the rule page.
What does a dated timeline look like?
A hospital outpatient claim is denied on a remittance advice dated Wednesday, March 10, 2027. The dates below use the 5-day receipt presumption and calendar days.
Count from the notice in your hand, and file well before the last day, because the request counts only when the named office receives it. A missed deadline can be excused only on a written good cause request, which each level judges under the standards in 405.942(b)(2) and (3).
How do you keep an appeal from stalling?
- Keep one file per claim with each notice, the proof of delivery and the date of receipt.
- Calendar the presumed receipt date, not the mail date, and a work-by date two weeks earlier.
- Do not file a reopening and an appeal on the same issue; 42 CFR 405.980 bars reopening while an appeal is pending. A clerical error is a reopening, as the rule page explains.
- For each level, ask what the last notice told you was missing, and answer that first.
- Check the Medicare billing guide for contractor-specific submission routes, and the timely filing limits by payer page before you rebill instead of appealing.
Authorization-related denials follow the same path; see how to fix CO-197 prior authorization denials.
How Nucleus Align handles Medicare appeals
Our denial management team tracks each notice date and the filing deadline, and works denials within 48 hours of posting. For the method behind it, see the denial management playbook. Book a call to review your open Medicare denials, or return to the blog.
- 42 CFR part 405, subpart I, Medicare appeals · eCFR
- Original Medicare (fee-for-service) appeals · CMS
- 42 CFR 405.910 Appointed representatives · eCFR
- 42 CFR 405.1018 Submitting evidence · eCFR
- 42 CFR 405.1028 Review of evidence submitted by parties · eCFR
We check every rule, code and deadline against the official source. See our editorial policy.
Common questions
Straight answers from the team that does the work.
Ask a billing lead directly. A 20-minute call, Monday to Friday, 9am to 5pm Eastern.
01What are the levels of a Medicare appeal?
There are five: redetermination by the MAC, reconsideration by a QIC, an ALJ hearing, review by the Medicare Appeals Council, and judicial review in federal district court. Each starts with a written request filed with the office named on the last notice, within its own deadline.
02Can I add new evidence at the ALJ hearing level?
Only with a reason. Under 42 CFR 405.1018(c), evidence a provider did not submit before the QIC's decision must come with a statement explaining why it was not sent earlier, or it will not be considered. Section 405.1028(a) lists the good cause grounds the ALJ applies.
03Where do I file a Medicare reconsideration request?
With the QIC named on the redetermination notice, under 42 CFR 405.964(a). The request needs the beneficiary's name, Medicare number, the services and dates of service, the party's name and the name of the contractor that made the redetermination.
04Do I need an appointment of representative to appeal for a patient or a provider?
If someone files on a party's behalf, the appointment must be in writing, signed and dated by both, and filed with the appeal under 42 CFR 405.910(c). CMS provides form CMS-1696. An appointment is valid for one year from both signatures unless it is revoked.
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