Medicare appeal levels: from redetermination to federal court

What are the five levels of Medicare appeal?

Subpart I of 42 CFR part 405 sets out five levels for Medicare Part A and Part B appeals, and each one starts with a written request filed on time. Section 405.900(b) says the subpart covers appeals of initial determinations for benefits under Part A or Part B.

For levels 1 to 4 the receipt date is presumed to be 5 calendar days after the date on the notice, unless there is evidence to the contrary. A request counts as filed on the date the contractor, QIC or office named in the notice receives it, not the date you mail it.

A redetermination is the first appeal and is decided by the contractor, and section 405.948 requires an individual who was not involved in the initial determination to make it. Everything from level 2 up is outside the MAC.

What is the deadline for a redetermination, and can it be extended?

A redetermination request must be filed within 120 calendar days from the date a party receives the notice of the initial determination, under 42 CFR 405.942(a). For providers and suppliers that accept assignment, section 405.921(b) makes the remittance advice the notice of initial determination.

If the 120 days have passed, a party that shows good cause can ask the contractor for an extension. The request must be in writing and state why the redetermination was not filed on time. The contractor considers what kept the party from filing, whether its own actions misled the party, and any physical, mental, educational or linguistic limitation that prevented a timely request.

A request counts only when it arrives, so send it well ahead of the last day.

What is the amount in controversy for an ALJ hearing?

For requests filed in calendar year 2026 the amount in controversy is $200 for an ALJ hearing and $1,960 for judicial review. For requests filed on or after January 1, 2027 it is $200 for an ALJ hearing and $2,000 for judicial review. CMS publishes the figures each year in the Federal Register.

Section 405.1006(d) computes the amount remaining in controversy as the actual amount charged for the items and services in the disputed claim, minus any Medicare payments already made and any deductible or coinsurance that may be collected. An appeal that involves an identified overpayment uses the amount in the demand letter instead, and an estimate from statistical sampling and extrapolation uses the total estimated overpayment.

Claims that fall short can be combined. Section 405.1006(e) lets an appellant aggregate two or more claims already reconsidered by a QIC for an ALJ hearing if the claims involve the delivery of similar or related services, and the request for aggregation is filed within 60 calendar days after receipt of all the reconsiderations. Part A and Part B claims may be combined.

What happens if a level takes too long?

The regulation lets you skip ahead when a decision-maker runs past its time limit. This is called escalation, and it keeps a stalled appeal moving.

• QIC to ALJ: if the QIC has not decided within its period under 405.970, you can ask the QIC to escalate the case to an ALJ hearing, provided the amount in controversy is met (405.1002(b)).
• ALJ to Council: if the ALJ or attorney adjudicator has not decided within 90 days (180 days for an escalated case), you can request escalation to the Council in writing with OMHA (405.1016).
• Council to federal court: if the Council has not acted within its period under 405.1100, you can request escalation to federal district court (405.1132). You then have 60 calendar days from the Council's notice that it cannot decide to file the civil action.

Each reviewer's period is extended when you submit new evidence: the MAC and the QIC add up to 14 calendar days for each submission (405.950(b)(3), 405.970(b)(3)).

Can I appeal a claim denied for no medical necessity?

Yes. Section 405.924(b) makes a determination of whether items or services are covered under Medicare an initial determination, and initial determinations have appeal rights. A denial that cites an LCD or NCD is the usual case; see LCDs and NCDs for how those policies are written and what the MAC checks.

Two denials do not follow this path. Section 405.924(b) says a finding that a submission does not meet the requirements for a Medicare claim is not an initial determination, and Claims Processing Manual chapter 1, section 70.4, says an untimely-filing denial is not an initial determination and not appealable. For that, read timely filing limits by payer and CO-29.

Claims Processing Manual chapter 1, section 70.2.3.2 also draws a line that matters on the remit: returned-to-provider submissions are not claims, rejections can be corrected and resubmitted, and denials are subject to appeal because a denial is a payment determination.

When should I ask for a reopening instead of an appeal?

Use a reopening for errors that were not a judgment call, such as keying mistakes or a duplicate denial that was not a duplicate. Section 405.980(a)(3) tells contractors to process clerical errors, defined to include mathematical or computational mistakes, inaccurate data entry and denials as duplicates, as reopenings and not as redeterminations.

While an appeal is pending on an issue, no adjudicator can reopen it, and a decision on whether to reopen is binding and not appealable (405.980(a)(4) and (a)(5)). Pick one route per issue. The overpayment link is explained in the 60-day overpayment rule.

How do commercial appeal levels compare to Medicare?

Medicare's levels, deadlines and dollar thresholds are fixed by regulation, while commercial plans set their own in the contract and the payer manual. Subpart I covers Part A and Part B initial determinations only, so a Medicare Advantage plan or a commercial payer is not bound by these numbers.

The practical difference is that Medicare gives a defined sequence with an outside decision-maker at level 2, and a commercial dispute may end at the payer's own internal review. Check the appeal section of the payer manual and the filing window in your agreement before you plan. The Medicare billing guide covers contractor-specific habits, and the denial management playbook covers how to prioritize appeals by dollar value.

If this rule is costing you claims, our denial management team can help, and unpaid balances waiting on appeal are tracked in accounts receivable follow-up.