Original Medicare: five levels
| Level | Who decides | Deadline to ask |
|---|---|---|
| 1. Redetermination | The Medicare Administrative Contractor that processed the claim | By the date on your Medicare Summary Notice (generally 120 days) |
| 2. Reconsideration | A Qualified Independent Contractor (QIC) | 180 days after the level 1 decision |
| 3. Hearing | An Administrative Law Judge or attorney adjudicator (OMHA) | 60 days after the QIC decision; a minimum amount in dispute applies |
| 4. Review | The Medicare Appeals Council | 60 days after the level 3 decision |
| 5. Judicial review | Federal district court | 60 days after the Council's decision; a minimum amount applies |
How to file a first appeal
- Find the notice. For Original Medicare it's your Medicare Summary Notice; for a plan, the denial letter. Circle the items you disagree with.
- Get support from your doctor. A letter or records explaining why the care was medically necessary help most.
- File in writing. Follow the notice's instructions, or use form CMS-20027 for an Original Medicare redetermination. Include your name, Medicare number, the items and why you disagree.
- Keep copies and track dates. Write down when you mailed it and who you spoke with.
Medicare Advantage and drug plans
Ask your plan for a reconsideration within 65 days of its denial notice. Medicare.gov says the plan has 30 days to decide a request for care you haven't received, 60 days for a payment request, 7 days for a Part B drug, and 72 hours for a fast appeal. If the plan still says no, your case goes to an Independent Review Entity automatically. Part D drug plans work in a similar way, starting with a coverage determination or exception request. Later levels match Original Medicare's.
Tip: If you have both Medicare and SoonerCare, a SoonerCare denial follows the Oklahoma Health Care Authority's own appeal process; the notice explains it. See SoonerCare and Medicare.
Related questions
How do I appeal a hospital discharge?
The fast QIO appeal.
How can I help a parent with Medicare?
Acting as a representative.
Medicare phone numbers for Oklahoma
Who to call.
More in Medicare appeals in Oklahoma and Oklahoma Medicare contacts.
Sources
- Medicare.gov — Appeals in Original Medicare
- Medicare.gov — Appeals in Medicare health plans
- CMS — Form CMS-1696, Appointment of Representative
- Acentra Health — BFCC-QIO, Oklahoma
More questions in this guide
- How can I help my parent with Medicare in Oklahoma?
- How do I appeal a hospital discharge in Oklahoma if I'm not ready to go home?
- How do I find a licensed insurance agent for Medicare in Oklahoma?
- How do I report Medicare fraud in Oklahoma?
- What are the Medicare phone numbers for Oklahoma?
- Where is the Social Security office near me in Oklahoma?
Part of the guide: Oklahoma Medicare contacts · All questions
Frequently asked questions
Can someone file the appeal for me?
Yes. You can name a family member, friend, doctor or lawyer as your representative with form CMS-1696, Appointment of Representative, or other written authorization. Your doctor can also request some appeals for you.
What if my health could be harmed by waiting?
Ask your Medicare Advantage or drug plan for a fast (expedited) decision. Medicare.gov says a plan must decide a fast appeal within 72 hours. If a doctor says waiting could seriously harm your health, the plan generally must speed it up.
Is a hospital discharge appealed the same way?
No. If you think your hospital stay or other covered care is ending too soon, you ask for a fast appeal from Acentra Health, the BFCC-QIO for Oklahoma, at 1-888-315-0636 (TTY 711).
Medicare in your Oklahoma county
Plans, local agents and help, county by county: Oklahoma · Tulsa · Cleveland · Canadian · Comanche · Rogers · Wagoner · Payne · Pottawatomie · Creek · Muskogee · Garfield · Grady · Washington · Logan · Bryan · Le Flore · Carter · Cherokee · McClain · All 77 counties →
