Medicare Appeals and Your Rights

The Five Levels of Medicare Appeals Overview

There are five levels of Medicare appeals, and each level has steps that you and your health plan must follow. In each of these five levels of appeal, you have the right to have someone help you with your appeal, such as a friend, family member, doctor or lawyer. More information about each level of appeal can be found below.

First Level of Appeal
Second Level of Appeal
Third Level of Appeal
Fourth Level of Appeal
Fifth Level of Appeal

The First Level Appeal: Health Plan Reconsideration

If you requested services or payment from your plan and your plan decided to deny all or part of what you requested, you can ask your plan to reconsider their decision. This is called an appeal or request for reconsideration.

The Second Level Appeal: Independent Review Entity (IRE) Reconsideration

If your health plan does not change its decision after your request for reconsideration, the plan automatically sends your case file to C2C, which is the IRE, for a reconsideration.

C2C’ reconsideration includes the following:

C2C will send you and your representative, if you have one, a letter stating that they have your case file
C2C will carefully review the Medicare rules, your agreement with the health plan, all of the information in your case file and any additional information that you provide
C2C will make a decision in the following timeframes:
1. 72 hours, or up to 17 days in certain cases, for an expedited (i.e., fast) review
2. 30 to 44 days for health care you are waiting for
3. 30 to 60 days for payment of a denied bill
C2C will send you a letter with the decision
1. If C2C disagrees with the plan (i.e., overturns the plan's denial), then C2C will send a letter to you and a letter to your health plan telling your health plan to pay for or provide for your health care
2. If C2C agrees with your health plan (i.e., upholds the plan's denial), your letter will tell you what you can do (Note: If you want to appeal this decision, you can ask for the third level appeal, which is an ALJ hearing)

Your Rights During the Second Level of Appeal

You have the right to send us information about your case. We must receive this information no later than 10 days after the date you receive C2C’s letter telling you we have your case file. You can have someone—such as a friend, family member, doctor or lawyer—help you write this information. Please include your name and appeal number. The mailing addresses are available in the side menu to left.
You have the right to ask C2C to send letters in a language you understand.
You have the right to a copy of your case file.
You have the right to receive a written appeal decision from C2C.

The Third Level Appeal: Administrative Law Judge (ALJ) Hearing

If you do not agree with the decision made by C2C, you may request an ALJ hearing. For more information about how to request an ALJ hearing, review our webpage about the process: How to Request an ALJ Hearing

What to Expect

Office of Medicare Hearings and Appeals will schedule your hearing and tell you the time and place of the hearing.
During your hearing, you will provide information about your case.
- Your health plan may also have someone at the hearing to give information.
- You can include anyone to speak for you or help you. This person does not have to be a lawyer. For example, it may be a friend, family member or doctor.
The ALJ will make a decision based on your case file and the information provided during the hearing.
The ALJ will send the written decision to you, your health plan and to C2C.
If the ALJ agrees with you, C2C will send a letter to your health plan telling them to pay or provide for your health care.

The Fourth Level Appeal: Medicare Appeals Council Review

If you do not agree with the decision made by the ALJ, you may be able to ask for the Medicare Appeals Council to review your case. For more information about the fifth level of appeals, visit the United States Department of Health and Human Services Departmental Appeals Board (DAB) webpage.

The Fifth Level Appeal: Federal Court

If you do not agree with the decision made by the Medicare Appeals Council, you may be able to take your case to a federal court. For more information about the fifth level of appeals visit the CMS Fifth Level of Appeal: Judicial Review in Federal District Court webpage.

Learn More About Your Rights and Who Can Help You

To get more information about your appeal rights:

Visit the Medicare website
Review the Medicare Rights & Protections booklet
Talk to your health plan about how to file appeals and your rights

To get help with your appeal:

Your local bar association or legal aid program
A private lawyer who will charge you
Your state's State Health Insurance Assistance Program (SHIP) (Note: Information regarding specific SHIPs can be accessed through the SHIP website)
Your State Health Insurance Assistance Program (Note: Call 1-800-MEDICARE (1-800-633-4227) to request the telephone number of your State Health Insurance Assistance Program; TTY users should call 1-877-486-2048)

Please review the CMS Accessibility & Nondiscrimination Notice for information about the availability of auxiliary aids and services.

Quality of Care Complaints

C2C cannot investigate quality of care complaints. Medicare has special organizations called Quality Improvement Organizations that can investigate quality of care complaints.

Information regarding specific Quality Improvement Organizations can be accessed through the CMS Quality Improvement Organizations webpage.