The Five Appeals Levels of Original Medicare

mgbrousse
Apr 28
4 min read

By Martine G. Brousse (not AI!)

"The Medical Bill Whisperer"™

Patient Advocate, Certified Mediator

AdvimedPro

April 28, 2025

The Original Medicare allows five levels of appeals.

What are they? What should you know about them?

A. Definitions

1. What is Medicare?

Medicare is the health insurance provided to folks 65 year old or older, but also, if they are permanently disabled, have end stage renal disease or ALS.

2. Types of Medicare plans

· Original Medicare is administered directly by CMS, the federal government agency that sets policies, supervises programs, processes and pays claims, maintains a provider database and ensures members rights

· Medicare Advantage plans or Part C are administered by private commercial carriers that get paid premiums to provide care and pay your claims, for example, Blue Cross Blue Shield plans or Kaiser HMO

· While both types of plans allow for five levels of appeals, the destination for some levels will differ.

3. What is an “Appeal”?

· It is your right to request that Medicare review a denial, a rejection of coverage or services review also an adverse decision of how a claim was processed

· It is your right to request a reconsideration of a decision based on medical records,

documentation, facts, terms of policy, legal mandates, medical policies, etc

· It is your right to request a review of a negative decision and to request that a payment

be made, coverage be applied approval be obtained and that benefits, and your member’s rights be enforced.

B. Five levels of Appeals

1. First level: Redetermination

· It goes to the MAC, which is the administrative regional administrator that processed the claim originally.

· Its contact and address are indicated on the explanation of benefit, also called a Medicare Summary Notice

· A special form called the Medicare Redetermination Request Form First Level of Appeal must be used. Explain exactly why your claim should be reprocessed and paid or why coverage should be approved.

2. Second level: QIC External Review

· This is an independent external reviewer that did not take part in the first decision or rejection of a positive outcome

· The Qualify Independent Contractor appeal also requires a special form

3. Third level: OMHA or Office of Medicare Hearings and Appeals

· Here, you can present your case and your evidence to an administrative law judge (ALJ) with a special form

· This hearing is held via phone or Zoom, and in person on rare occasions with the judge’s approval

· you must send all the documentation you will refer to ahead of time to that judge’s clerk

4. Fourth level: Medicare Appeals Council Review

· This level is not in person, via zoom or by phone.

· You must be mail your evidence, arguments, justifications, records etc to their Washington, DC address.

· If the decision is still negative, if at that time the decision is still negative, the decision letter will indicate the steps to file your last level of appeal

5. Fifth level: Judicial Review in a Federal District Court

· instructions on how to file will be indicated on the MACR’s decision letter

· Making certain that every document, argument, piece of evidence is included in that written, mailed case package is imperative.

· Preparation and appearance will likely require the assistance of a specialized attorney.

C. What to be aware of:

1. Timeliness for filing every level of appeal is precise and strictly enforced:

· 180 days to start the process appeal level 1 and 2 based on the date of the Medicare Summary Notice. But after that, those 180 days dwindle down to 60 days.

· There are some exceptions: you were in the hospital or skilled nursing facility, very ill or incapacitated. If an immediate family member was quite sick or passed away, if the necessary records were destroyed or damaged in a natural or uncontrollable disaster, you can claim an extension. If you were given incorrect information by an official Medicare representative, you can also file for an extension. And I have found that if you hire a representative, advisor or patient advocate, the date of hire can be considered as an exceptions. It is not guaranteed, though.

2. Minimum $ amount required

· In 2025 you must have at least $190.00 accumulated, or in one claim, to file a request for a level 3 ALJ appeal.

. To file that request for Level Five federal court, $1,850 are the minimum.

3. Getting help is OK… and recommended

· Your local State Health Insurance Assistance Program (SHIP) navigators can provide free advice and assistance with the appeal process: how to file, where to find the form. How much time do you have? How to best prepare for hearing? and more.

· Should you prefer to hire a specialized advocate or have someone help you, you must give another form called an Appointment Of Representative (“AOR”) which informs Medicare that you have given authorization to that third party to handle an appeal on your behalf and be involved in the decision process

· By the time you reach level 4 and certainly 5, hiring a specialized attorney may be the difference between success or not.

In conclusion:

In all my years as a billing manager and patient advocate, I have never gone through level 4 or level 5. I have won almost all cases on level 1 or level 3.
Good preparation, clear evidence and a concise presentation best lead to success.
Being aware that you have five appeal levels should never be forgotten. This is your right as a Medicare member, even if - hopefully ! - you never have to use it.

Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.