Medicare Fee-for-Service Appeals: The Five Levels

Medicare Fee-for-Service (Original Medicare) Appeals — Five Levels#

Medicare has a formal, statutory five-level appeals process for Part A and Part B claim denials. The terminology differs from commercial appeals — note especially "redetermination" and "reconsideration," which mean specific, *different* things in Medicare.

Level 1 — Redetermination by the Medicare Administrative Contractor (MAC). The first appeal of an initial claim determination. File within 120 days of receiving the Medicare Remittance Advice / Medicare Summary Notice. The MAC issues a redetermination decision (the Medicare Redetermination Notice), generally within 60 days.

Level 2 — Reconsideration by a Qualified Independent Contractor (QIC). If dissatisfied with the redetermination, request reconsideration within 180 days. The QIC is independent of the MAC. A reconsideration generally must be decided within 60 days.

Level 3 — Hearing before an Administrative Law Judge (ALJ) at the Office of Medicare Hearings and Appeals. File within 60 days of the reconsideration. There is a minimum amount-in-controversy threshold (adjusted annually).

Level 4 — Review by the Medicare Appeals Council. File within 60 days of the ALJ decision.

Level 5 — Judicial review in U.S. District Court. Available when the amount in controversy meets the annual threshold; file within 60 days of the Council decision.

Key distinction vs. commercial appeals: In Medicare, *redetermination* (Level 1, by the MAC) precedes *reconsideration* (Level 2, by the QIC). In commercial/ERISA plans those words are used loosely and the structure is internal-internal-external. Mixing up the two processes — and their different deadlines — is a common, costly denial-management error.