Medicare (Original)

Appeal Deadlines

Commercial: 120 days from denial for Part B

Medicare: 60 days for Part A

Key Facts

• +Original Medicare has a five-level appeals process: Redetermination, Reconsideration, ALJ Hearing, Medicare Appeals Council, Federal Court.
• +Part A appeals deadline is 60 days from the date of the denial notice. Part B appeals deadline is 120 days.
• +Medicare denied 28.8% of prior authorization requests in 2023 -- higher than most Medicare Advantage plans.
• +Medicare's coverage determinations are governed by National Coverage Determinations (NCDs) and Local Coverage Determinations (LCDs) which are publicly available.

What to Watch

• +Medicare appeals must be filed at the correct level and within the correct deadline. Missing a deadline forecloses that level of appeal.
• +If you are in a Medicare Advantage plan rather than Original Medicare, the appeal process goes through your plan first, not through CMS directly.

Appeal Tips

1. File a Redetermination (Level 1 appeal) within 120 days. This is handled by your Medicare Administrative Contractor.
2. If the Redetermination is denied, request a Reconsideration (Level 2) through a Qualified Independent Contractor within 180 days.
3. Reference the specific NCD or LCD that covers your service. If no NCD or LCD exists, Medicare coverage is generally available for services considered reasonable and necessary.
4. A Medicare State Health Insurance Assistance Program (SHIP) counselor can help you navigate the appeals process for free.

Resources

• Medicare Coverage Determinations
• Medicare Appeals
• Find a SHIP Counselor