How long do I have to appeal a Medicare denial?

120 days from the initial denial to request Level 1 redetermination for Original Medicare. 180 days from the Level 1 decision to request Level 2 reconsideration. 60 days from each subsequent level. For Medicare Advantage and Part D, timelines are shorter (typically 60-90 days for each level). Read your denial letter carefully — it specifies the exact deadline for your situation.

Can I appeal a Medicare Advantage prior authorization denial?

Yes. MA prior authorization denials follow the same 5-level appeals process. Submit Level 1 (Plan Redetermination) to your MA plan with medical records supporting necessity. Standard decision in 30 days; expedited (when waiting could harm health) in 72 hours. Many prior auth denials are overturned at Level 1 or Level 2 when supporting medical documentation is provided. Federal regulations have tightened MA prior authorization rules in recent years; some denials may not be permitted under new rules.

Do I need a lawyer for a Medicare appeal?

Not for Levels 1 and 2 — most beneficiaries handle these themselves with help from OSHIIP or family members. For Level 3 (ALJ hearings), legal representation is helpful but not required; some beneficiaries are represented by family members or non-attorney advocates. For Levels 4 and 5 (Appeals Council and federal court), legal representation is generally necessary given the legal complexity.

What happens if my appeal succeeds?

If your appeal is approved, Medicare pays the previously-denied claim, and you may be reimbursed for any out-of-pocket amounts you paid in the interim. Ongoing services receive coverage going forward. Sometimes the appeal decision orders specific changes — for example, removing a prior authorization requirement for similar future services with the same diagnosis.

Can I keep getting the service while my appeal is pending?

Yes for ongoing services in most cases — Medicare allows continuation of services during the appeal process for certain situations like SNF or home health discharge appeals. For Medicare Advantage, you may continue receiving the service if you appeal within 60 days, with the plan continuing to pay during the appeal. For new services or new denials, expedited review (72-hour decision) may apply if delaying would harm your health.

Where do I send a Medicare appeal in Ohio?

Original Medicare appeals go to the Medicare Administrative Contractor (MAC) that processed your original claim. For Ohio Original Medicare, that's CGS Administrators (DME claims) or Novitas Solutions (Part A and Part B claims). The denial letter you received specifies the exact address. Medicare Advantage appeals go to your MA plan. Part D appeals go to your Part D plan. The denial letter always specifies where to submit your appeal.

How to Appeal a Medicare Decision in Ohio (2026)

On this page

The 5 levels of Medicare appeals
Time limits at each level
Level 1: Redetermination
Level 2: Reconsideration
Levels 3-5: ALJ, Council, federal court
Special rules for MA and Part D appeals
Ohio resources for appeals help
Common questions

The 5 levels of Medicare appeals

Medicare's appeal structure is the same regardless of whether you're appealing Original Medicare, Medicare Advantage, or Part D — though the specific contractors and timelines vary. The 5 levels:

Redetermination — by your Medicare contractor (or MA/Part D plan for those programs). First chance to overturn the denial.
Reconsideration — by an independent Qualified Independent Contractor (QIC). Second-level review by someone not involved in the first decision.
Administrative Law Judge (ALJ) hearing — formal hearing before an ALJ at the Office of Medicare Hearings and Appeals. Requires the disputed amount to exceed a minimum threshold ($190 in 2026 for most cases).
Medicare Appeals Council review — review by the Council, an appellate-level body within HHS.
Federal District Court — last resort. The disputed amount must exceed a higher minimum threshold ($1,890 in 2026 for most cases). Court appeals require legal representation in practice.

Most Medicare appeals are resolved at Level 1 or Level 2. The higher levels are reserved for complex cases or significant disputed amounts.

Time limits at each level

Appeal level	Deadline to file from prior decision	Standard decision timeline
Level 1 (Redetermination)	120 days from initial denial	60 days (Original Medicare)
Level 2 (Reconsideration)	180 days from Level 1 decision	60 days (Original Medicare)
Level 3 (ALJ hearing)	60 days from Level 2 decision	~90 days, often longer
Level 4 (Council)	60 days from ALJ decision	~90 days
Level 5 (Federal court)	60 days from Council decision	Months to years

Expedited (fast-track) appeals are available when waiting for the standard timeline could seriously harm your health — typically 72 hours for the appeal decision. Request expedited review if your health would be at risk during the standard timeline.

Level 1: Redetermination

To file a Level 1 redetermination for an Original Medicare denial:

Read your Medicare Summary Notice (MSN) or denial letter carefully. It explains why the claim was denied and how to appeal.
Gather supporting documentation: medical records, doctor's letters supporting medical necessity, billing details.
Complete the redetermination request form (CMS-20027) or write a letter including: your name, Medicare number, claim number, date of service, reason for appeal, and signature.
Submit within 120 days of the initial denial. Mail to the address on your MSN.
The Medicare contractor has 60 days to issue a redetermination decision for Original Medicare. For MA and Part D, the timeline is shorter (typically 14-30 days).

Many Medicare appeals succeed at this level. The contractor reviews the denial fresh; if medical records support the service, the denial is often overturned without needing to go further.

Level 2: Reconsideration

If Level 1 is denied, you can request Level 2 reconsideration:

Submit within 180 days of the Level 1 decision.
Use form CMS-20033 or write a letter. Include all documentation from Level 1 plus any additional supporting information.
An independent Qualified Independent Contractor (QIC) reviews the case. This is someone different from the Level 1 reviewer — important for an independent perspective.
The QIC has 60 days to issue a decision (shorter for MA and Part D).

Level 2 success rates are decent, especially when you bring new evidence or specific medical justification that wasn't in the Level 1 file.

Levels 3-5: ALJ, Council, federal court

If Levels 1 and 2 both deny, the higher levels are available:

Level 3 (ALJ hearing): Formal proceeding with an Administrative Law Judge. You can present your case in person, by phone, or by video conference. The disputed amount must exceed approximately $190 (2026). Many beneficiaries are represented by family members, attorneys, or non-attorney advocates at this level.
Level 4 (Medicare Appeals Council): Appellate-level review of ALJ decisions, focused on legal interpretation and correctness rather than re-hearing facts.
Level 5 (Federal District Court): Last resort. The disputed amount must exceed approximately $1,890 (2026). Federal court appeals typically require legal representation and involve significant cost and time investment.

The OMHA (Office of Medicare Hearings and Appeals) has historically had significant backlogs at the ALJ level — sometimes 18-36 months between filing and hearing. CMS has worked to reduce backlogs, but expect delays.

Ohio Medicare beneficiary facing a denial?OSHIIP counselors and a licensed Ohio Medicare agent can help you understand your denial and decide whether to appeal. For complex appeals, Ohio Legal Aid organizations provide free representation for low-income beneficiaries.

Find a Medicare Agent in Ohio

Special rules for MA and Part D appeals

Medicare Advantage and Part D appeals follow the same 5-level structure but with shorter timelines and different first-stage contractors:

MA Level 1 (Plan Redetermination): Your MA plan reviews the denial. Decision in 30 days for standard requests, 72 hours for expedited.
MA Level 2 (IRE — Independent Review Entity): An independent contractor reviews. Decision in 30 days standard, 72 hours expedited.
Part D Level 1 (Coverage Determination Review): Your Part D plan reviews the denial. Decision in 7 days for standard, 72 hours expedited.
Part D Level 2 (IRE Review): Independent review. 7 days standard, 72 hours expedited.

For MA prior authorization denials (which have been a growing concern), the appeal process is the same — submit Level 1 to the plan, with medical records supporting necessity. Many prior authorization denials are overturned at Level 1 or Level 2.

Ohio resources for appeals help

Several Ohio organizations help Medicare beneficiaries with appeals:

OSHIIP at 1-800-686-1578 — free counseling on Medicare appeals, including help understanding denials and the appeal process. Doesn't represent you in formal hearings but provides guidance.
Ohio Legal Aid Society (and county-specific legal aid organizations) — free legal representation for low-income beneficiaries on Medicare appeals. Includes the Legal Aid Society of Cleveland, Legal Aid Society of Columbus, Legal Aid of Southwest Ohio (Cincinnati), Legal Aid of Western Ohio (Toledo), and Community Legal Aid Services (Akron/Canton).
Center for Medicare Advocacy — national nonprofit providing Medicare appeals resources, sample letters, and (selectively) direct representation.
Medicare Rights Center — national consumer service with a free helpline and online resources for navigating appeals.
Ohio State Bar Association Lawyer Referral Service — for finding attorneys who handle Medicare appeals at Levels 3-5.