Medicare Denials

Overview – Standard Medicare Fee-For-Service Appeals Process

Once an initial claim determination is made, any party to that initial determination, such as beneficiaries, providers, and suppliers – or their respective appointed representatives – has the right to appeal the Medicare coverage and payment decision.

There are five levels in the Medicare Part A and Part B appeals process. The levels are:

  1. First Level of Appeal: Redetermination by a Medicare Administrative Contractor (MAC)
  2. Second Level of Appeal: Reconsideration by a Qualified Independent Contractor (QIC)
  3. Third Level of Appeal: Decision by the Office of Medicare Hearings and Appeals (OMHA)
  4. Fourth Level of Appeal: Review by the Medicare Appeals Council
  5. Fifth Level of Appeal: Judicial Review in Federal District Court

The CMS Main Page on Medicare Appeals is located here: https://www.cms.gov/Medicare/Appeals-and-Grievances/OrgMedFFSAppeals