How to File a Medicare Appeal If Your Claim Is Denied

Got a denied Medicare claim? You have the right to appeal. Here's a step-by-step guide to the five levels of Medicare appeals.

Receiving a Medicare claim denial can be frustrating and scary, especially when you need medical services. But here's the important thing to know: you have the right to appeal every Medicare denial, and a significant percentage of appeals are successful. According to data from the Office of Medicare Hearings and Appeals, approximately 50% of Medicare appeals are decided in favor of the beneficiary. Here's how the process works and how to navigate each level.

Appeals Work

Don't accept a denial without fighting it. Studies show that about half of Medicare appeals result in the denial being overturned. The appeals process exists to protect your rights, and it's free to use.

The Five Levels of Medicare Appeals

Medicare has a five-level appeals process. You must start at Level 1 and can escalate to each subsequent level if your appeal is denied. Each level has its own deadline and process.

Step-by-Step: Filing Your Appeal

Step 1: Understand Why Your Claim Was Denied

Before filing an appeal, carefully read your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB). It will include a reason code explaining why the claim was denied. Common reasons include:

Service not deemed medically necessary
Provider coding error (wrong diagnosis or procedure code)
Service not covered by Medicare
Prior authorization was required but not obtained
Out-of-network provider (for Medicare Advantage plans)
Timely filing deadline missed by the provider

Step 2: Gather Supporting Documentation

Your Medicare Summary Notice (MSN) or Explanation of Benefits (EOB) showing the denial
A letter from your doctor explaining why the service is medically necessary
Medical records, test results, and treatment history that support your case
Any relevant clinical guidelines or Medicare coverage criteria
A personal statement describing how the service affects your health and daily life

Step 3: File Your Level 1 Appeal

For Original Medicare, you can file by mailing or faxing a written request to the Medicare contractor listed on your MSN. Include the MSN, your supporting documentation, and a clear explanation of why you believe the denial should be overturned. For Medicare Advantage plans, contact your plan directly — many accept appeals by phone, online, or by mail.

Ask for an Expedited (Fast) Appeal

If waiting for a standard decision could seriously harm your health, you can request an expedited appeal. For Medicare Advantage plans, an expedited appeal must be decided within 72 hours (compared to 30 days for a standard appeal). Ask your doctor to support the expedited request.