Every year, Medicare denies over 4 million claims — including many that are completely valid. The vast majority of seniors simply accept the denial, pay out of pocket, or go without care.
What they don’t know: the appeal success rate is over 50%. In some case types, seniors win 60–80% of appeals. The system is designed to be confusing — but the process is straightforward when you know the steps.
The 5 Levels of Medicare Appeal
Medicare has five formal levels of appeal, each escalating to a higher authority. Most cases are resolved at Level 1 or 2.
Level 1: Redetermination
Who reviews it: The same Medicare contractor who made the original decision
Time limit: File within 120 days of the denial
Decision time: 60 days (30 days for fast-track)
How to file: Submit Form CMS-20027 to the address on your Explanation of Benefits (EOB)
Level 2: Reconsideration
Who reviews it: A Qualified Independent Contractor (QIC) — completely separate from Level 1
Time limit: File within 180 days of Level 1 decision
Decision time: 60 days
How to file: Submit Form CMS-20033 to the QIC listed in your Level 1 decision letter
Level 3: Office of Medicare Hearings and Appeals (OMHA)
Who reviews it: An Administrative Law Judge (ALJ) — completely independent
Minimum amount in controversy: $180 in 2026
Time limit: 60 days from Level 2 decision
Step-by-Step: How to File a Level 1 Appeal
1
Find your denial notice — either your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB). This contains the exact reason for denial and the address to send your appeal.
2
Get a letter from your doctor explaining why the service was medically necessary. This is the single most important document in your appeal — a physician statement dramatically increases your chances of winning.
3
Complete Form CMS-20027 (free download at CMS.gov). Fill in your Medicare number, the claim details, and a brief explanation of why you believe the claim should be covered.
4
Send it certified mail with return receipt to the address on your MSN or EOB. Keep a copy of everything you send.
5
Follow up after 30 days if you haven’t heard back. Call 1-800-MEDICARE with your appeal reference number.
💡 Free Help Available: Your State Health Insurance Assistance Program (SHIP) provides free, unbiased help with Medicare appeals. SHIP counselors know the system inside-out and can dramatically improve your chances of winning. Call 1-800-MEDICARE to find your local SHIP number.
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