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Medicare Appeal Timeframes
Federal appeal timeframes for Original Medicare, Medicare Advantage, and Part D, organized by stage. Your specific deadline is in your denial letter — use these tables for the calendar shape, then verify.
How to use this page
- Find your specific deadline. Read the denial letter from Medicare or your plan. The letter states the deadline that applies to your situation. The tables below show the general standard; your letter is authoritative for your specific case.
- Identify which path applies to you. Original Medicare, Medicare Advantage, or Part D. Each path has its own table below.
- Identify which stage you are at. Most appeals start at Level 1 (redetermination or reconsideration). Higher levels follow if a previous level denied your appeal.
- Confirm with your plan or your state SHIP before the deadline passes. SHIP counselors can help you understand the process for free. Find your state's SHIP at shiphelp.org.
- Do not rely on this page alone for a specific deadline. Use it for the calendar shape and then verify with the authoritative sources.
Original Medicare appeals
For services covered under Parts A and B. The appeal starts after you receive a Medicare Summary Notice (MSN) showing a service that was not covered or was paid less than expected.
| Level | Stage | Timeframe to file | Decision timeframe | Who decides |
|---|---|---|---|---|
| 1 | Redetermination | 120 days from the date on the Medicare Summary Notice | Generally 60 days from receipt | Medicare Administrative Contractor (MAC) |
| 2 | Reconsideration | 180 days from the redetermination notice | Generally 60 days from receipt | Qualified Independent Contractor (QIC) |
| 3 | Administrative Law Judge (ALJ) hearing | 60 days from the QIC reconsideration notice | Generally 90 days, with case backlog variation | Office of Medicare Hearings and Appeals (OMHA) |
| 4 | Medicare Appeals Council review | 60 days from the ALJ decision | Generally 90 days | Departmental Appeals Board |
| 5 | Federal District Court review | 60 days from the Council decision | Court schedule | Federal District Court |
Notes for Original Medicare:
- The ALJ level (Level 3) has a minimum dollar threshold that adjusts annually. Verify the current threshold at Medicare.gov — File an Appeal.
- The Federal District Court level (Level 5) has a higher dollar threshold that also adjusts annually.
- Expedited appeals are available for situations where the standard timeline would jeopardize your health.
Official source: Medicare.gov — File an Appeal →
Medicare Advantage appeals
For services covered under a Medicare Advantage plan. The appeal starts after you receive a denial notice from your plan.
| Level | Stage | Timeframe to file | Decision timeframe | Who decides |
|---|---|---|---|---|
| 1 | Plan reconsideration (standard) | 60 days from the denial notice | Generally 30 days for service requests, 60 days for payment requests | Your Medicare Advantage plan |
| 1 | Plan reconsideration (expedited) | 60 days from the denial notice | Generally 72 hours for urgent situations | Your Medicare Advantage plan |
| 2 | Independent Review Entity (IRE) review | Automatic if the plan upholds the denial | Generally 30 days standard, 72 hours expedited | Independent Review Entity contracted by CMS |
| 3 | Administrative Law Judge (ALJ) hearing | 60 days from the IRE decision | Generally 90 days | Office of Medicare Hearings and Appeals |
| 4 | Medicare Appeals Council review | 60 days from the ALJ decision | Generally 90 days | Departmental Appeals Board |
| 5 | Federal District Court review | 60 days from the Council decision | Court schedule | Federal District Court |
Notes for Medicare Advantage:
- The plan reconsideration (Level 1) is filed with your plan, not with Medicare. The phone number and address are on your denial notice.
- If the plan upholds the denial at Level 1, the case is automatically sent to the Independent Review Entity at Level 2. You do not need to file separately for IRE review in most cases.
- Expedited timeframes apply to situations where the standard timeline would jeopardize your health. Ask your plan or your prescriber to request expedited review when medically appropriate.
- The ALJ and Federal District Court levels have minimum dollar thresholds that adjust annually.
Official source: Medicare.gov — Appeals in Medicare Advantage →
Part D drug coverage appeals
For prescription drug coverage decisions. The appeal starts after a coverage determination from the plan.
| Level | Stage | Timeframe to file | Decision timeframe | Who decides |
|---|---|---|---|---|
| 1 | Coverage determination request | Filed by you or your prescriber | Generally 72 hours for standard, 24 hours for expedited | Your Part D plan |
| 2 | Redetermination | 60 days from the coverage determination | Generally 7 days for standard, 72 hours for expedited | Your Part D plan |
| 3 | Independent Review Entity (IRE) reconsideration | 60 days from the redetermination | Generally 7 days for standard, 72 hours for expedited | Independent Review Entity contracted by CMS |
| 4 | Administrative Law Judge (ALJ) hearing | 60 days from the IRE decision | Generally 90 days | Office of Medicare Hearings and Appeals |
| 5 | Medicare Appeals Council review | 60 days from the ALJ decision | Generally 90 days | Departmental Appeals Board |
| 6 | Federal District Court review | 60 days from the Council decision | Court schedule | Federal District Court |
Notes for Part D:
- A coverage determination (Level 1) is the initial request to the plan for coverage of a specific drug, often involving formulary exceptions, tiering exceptions, prior authorization, step therapy waivers, or quantity limit exceptions.
- The prescriber's involvement is essential at most stages. Many exception and appeal requests must be supported by clinical documentation from the prescriber.
- Expedited timeframes apply to situations where the standard timeline would jeopardize your health.
- The ALJ and Federal District Court levels have minimum dollar thresholds that adjust annually.
Official source: Medicare.gov — Drug Coverage Appeals →
Common questions
How long do I have to appeal a Medicare denial?
The standard appeal window depends on which type of coverage and which stage. Original Medicare Level 1 (redetermination) is 120 days from the Medicare Summary Notice. Medicare Advantage Level 1 (plan reconsideration) is 60 days from the denial notice. Part D Level 2 (redetermination) is 60 days from the coverage determination. Your specific deadline is in your denial letter.
What happens if I miss the deadline?
If you miss the standard deadline, you may still be able to appeal if you can show good cause for the delay. Good cause is defined by CMS and can include illness, errors in the notice you received, or other circumstances beyond your control. Contact your plan, Medicare, or your state SHIP as soon as possible if the deadline has passed.
Can someone help me appeal?
Yes. Your state SHIP provides free unbiased counseling and can help you understand the appeal process. Some attorneys and patient advocacy organizations also help with Medicare appeals, sometimes at no cost depending on the case. Your prescriber or doctor's office can support a clinical appeal with documentation. You can also authorize a representative — a family member, attorney, or advocate — to file the appeal on your behalf.
What is an expedited appeal?
An expedited appeal is a faster process for situations where the standard timeline would seriously jeopardize your life, health, or ability to regain maximum function. Expedited decisions typically come within 72 hours rather than the standard timeframe. Ask your plan or your prescriber to request expedited review when medical urgency applies.
Where can I get help understanding my specific denial letter?
Your state SHIP is the standard recommendation for free unbiased help. Find your state's SHIP at shiphelp.org. You can also call 1-800-MEDICARE (1-800-633-4227) for federal-level questions, or call the member services number on your plan card for plan-specific questions.
Sources
This page reflects federal regulations governing Medicare appeals (42 CFR Parts 405, 422, and 423). Specific timeframes can be confirmed at:
- Medicare.gov — Claims & Appeals
- Medicare.gov — Your Medicare Rights
- Medicare.gov — File an Appeal
- Medicare.gov — Drug Coverage Appeals
- CMS.gov — Appeals & Grievances
For your specific situation, your denial letter and your state SHIP are the authoritative sources.
The Clearing does not sell Medicare plans, rank carriers, or earn commissions. This page is reference information, not legal or appeals advice. Verify any specific rules, dates, or costs with Medicare.gov, your state SHIP, your employer's benefits team, or a licensed professional. Your specific appeal deadline is stated in the denial letter you received.