Original Medicare standard appeals

If you have Original Medicare Original Medicare Original Medicare, also known as Traditional Medicare, is the fee-for-service health insurance program offered through the federal government, which pays providers directly for the services you receive. Almost all doctors and hospitals in the U.S. accept Original Medicare. and your health service or item was denied, you have the right to appeal. An appeal is a formal request you make if you disagree with a coverage or payment decision. Check your Medicare Summary Notice (MSN) to see if Medicare Medicare Medicare is the federal government health insurance program that provides health care coverage if you are 65 or older, are under 65 and receive Social Security Disability Insurance (SSDI) for 24 months, begin receiving SSDI due to ALS/Lou Gehrig’s Disease, or have End-Stage Renal Disease (ESRD) no matter your age. You can receive health coverage directly through the federal government (see Original Medicare) or through a private company (see Medicare Advantage). has paid for your services and how much you may owe your provider provider See Health Care Provider. . If your MSN says that Medicare did not pay for a service, and you think it should, call your doctor to make sure there was not a billing error before appealing.

Note: You can also appeal if you signed an Advance Beneficiary Notice (ABN). Before appealing, make sure that Medicare was billed and that you received a denial.

Follow the steps below if your health service or item was denied. Note that these steps are for a standard appeal, which you file if you have already received the service but Medicare is denying payment. You should file an expedited appeal if you disagree with a hospital’s or skilled nursing facility’s plans to discharge you, or if you disagree with a home health agency’s or hospice’s plans to end your care. For all kinds of appeal, you should keep a copy of all documents sent and received during the process.

1. Start your appeal by following the appeal instructions listed on your MSN or Redetermination Redetermination Redetermination is the first step in the Original Medicare appeals process once you have received a Medicare Summary Notice (MSN) with a denial of coverage or payment. It also refers to the first step in the Part D appeals process after the plan denies your coverage determination or exception request. Request form. This includes circling the denied service listed and filling out the shaded section at the end of the MSN. Then, send your appeal to the Medicare Administrative Contractor (MAC) Medicare Administrative Contractor (MAC) Medicare Administrative Contractors (MACs) are private companies that process Part A and Part B medical claims or Durable Medical Equipment (DME) claims for Original Medicare beneficiaries. Each MAC serves a defined geographic area. To find the MAC in your region, call 1-800-MEDICARE. within 120 days of the date on your MSN. (The MAC’s name and address are listed in the shaded section of your MSN.) This will start your appeal. The MAC should make a decision within 60 days.
   • If your provider sends you a bill for this service, let your provider’s billing office know that you are in the process of appealing Medicare’s coverage decision.
   • If you have a good reason for missing your appeal deadline, you may be eligible for a good cause extension.
2. If your appeal is successful, your service or item will be covered. If your appeal is denied, you can move on to the next level by appealing to the  Qualified Independent Contractor (QIC) Qualified Independent Contractor (QIC) A Qualified Independent Contractor (QIC) is an independent entity with which Medicare contracts to handle the reconsideration level of an Original Medicare (Part A or Part B) appeal. within 180 days of the date listed on the MAC denial letter. The QIC may go by a different name in your area. Follow the instructions on the MAC denial notice to file your appeal. The QIC should make a decision within 60 days.
3. If your QIC appeal is successful, your service or item will be covered. If your appeal is denied and your health service or item is worth at least $190 in 2025, you can choose to appeal to the Office of Medicare Hearings and Appeals (OMHA) level. You must file your OMHA level appeal within 60 days of the date on your QIC denial letter. If you decide to appeal to the OMHA level, you may want to contact a lawyer or legal services organization to help you with this or later steps in your appeal—but this is not required. OMHA should make a decision within 90 days.
4. If your appeal to the OMHA level is successful, your service or item will be covered. If your appeal is denied and your health service or item is worth at least $190 in 2025, you can choose to appeal to the Council within 60 days of the date on your OMHA level denial letter.
   • You may not receive an OMHA level decision within 90 days. If your appeal has spent more than 90 days at the OMHA level, you can ask OMHA to move the appeal on to the next level (the Council). Speak to an attorney to see if proceeding directly to the Council may be appropriate for you.
5. If your appeal to the Council is successful, your service or item will be covered. If your appeal is denied and your health service or item is worth at least $1,840 in 2025, you can choose to appeal to the Federal District Court Federal District Court The Federal District Court is the final level of the Medicare appeals process, following an unfavorable decision at the Medicare Appeals Council level. within 60 days of the date on your Council denial letter. There is no timeframe for the Federal District Court to make a decision.