Original Medicare appeal rights
For a standard Part A or Part B claim denial, the first step is a written redetermination by the Medicare Administrative Contractor (MAC) on your notice.
- Deadline
- 120 days after receipt of the initial determination
- File with
- The MAC identified on the Medicare Summary Notice
- How
- CMS Form 20027 or a complete written request
- General decision time
- The MAC generally issues a redetermination within 60 days
The five Original Medicare appeal levels
- MAC redetermination — a new review by the Medicare contractor.
- QIC reconsideration — review by a Qualified Independent Contractor.
- OMHA hearing — an administrative-law-judge level when requirements are met.
- Medicare Appeals Council — review of the prior decision.
- Federal district court — available when the statutory requirements are met.
What to put in the redetermination request
- Your name and Medicare number.
- The specific item or service and date of service.
- A copy of the Medicare Summary Notice or initial determination.
- A factual explanation of why the decision is wrong.
- Supporting clinician records and a letter tied to the coverage issue.
Original Medicare appeal questions
How long do I have to appeal an Original Medicare claim denial?
CMS says a standard redetermination request must be filed within 120 days after you receive the initial claim determination. Use the specific instructions on your Medicare Summary Notice.
Where do I send an Original Medicare appeal?
Send the first-level redetermination request to the Medicare Administrative Contractor identified on the Medicare Summary Notice or remittance advice—not to a state insurance department.
Is Original Medicare the same appeal route as Medicare Advantage?
No. Original Medicare Part A and Part B claims start with MAC redetermination. Medicare Advantage starts with a private plan reconsideration and uses its own Part C rules.
What if Medicare is ending hospital, home-health, hospice, or skilled-nursing care?
Some discharge and service-termination decisions have much shorter expedited procedures. Follow the notice immediately; do not rely on the standard 120-day claim-redetermination window for an urgent termination.
Primary sources
- CMS — First Level of Appeal: Redetermination by a Medicare Contractor
- CMS — Original Medicare (Fee-for-service) Appeals
- eCFR — 42 CFR Part 405, Subpart I