Quick answers
- How long do I have to file a Medicare appeal?
- 120 days from the date you get your Medicare Summary Notice for Original Medicare, and 65 days from the date on the denial notice for a Medicare Advantage or Part D plan.
- Who reviews hospital discharge appeals in Oregon?
- Acentra Health, the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for Oregon. Call 1-888-305-6759 (TTY 1-855-843-4776) no later than your planned discharge day.
- How fast is an expedited appeal?
- Medicare Advantage and Part D plans must decide a fast appeal within 72 hours when waiting could seriously harm your health. A fast Part D coverage request is decided within 24 hours.
- How do I report Medicare fraud in Oregon?
- Call 1-800-MEDICARE (1-800-633-4227) or the Senior Medicare Patrol Resource Center at 1-877-808-2468, which connects you with your state's SMP. You can also report to the HHS Office of Inspector General.
- Where do I complain about a Medigap company or insurance agent in Oregon?
- The Oregon Division of Financial Regulation's consumer advocates at 1-888-877-4894, or DFR.InsuranceHelp@oregon.gov.
If Medicare or your Medicare plan denies a service, drug or payment, you have the right to appeal. The rules differ for Original Medicare, Medicare Advantage and Part D drug plans, and each has up to five levels. This page walks through the deadlines, fast appeals, discharge reviews and where to get help in Oregon.
When you'd appeal
- Medicare or your plan won't pay for a service, item or drug you got or want.
- Your Medicare Advantage or Part D plan denied a prior authorization request.
- A drug isn't on your plan's formulary, or you need an exception to a plan rule.
- You think a hospital discharge, or the end of skilled nursing, home health or hospice care, is too soon.
- Medicare or your plan paid less than you think it should.
- You disagree with a late enrollment penalty or an income-related premium (IRMAA).
The five levels
| Level | Original Medicare | Medicare Advantage | Part D |
|---|---|---|---|
| 1 | Redetermination by the Medicare Administrative Contractor | Reconsideration by the plan | Redetermination by the plan |
| 2 | Reconsideration by a Qualified Independent Contractor | Independent Review Entity (automatic if the plan upholds its denial) | Independent Review Entity (you request it) |
| 3 | Hearing before an Administrative Law Judge (Office of Medicare Hearings and Appeals), if a minimum amount is in dispute | ||
| 4 | Review by the Medicare Appeals Council | ||
| 5 | Federal district court, if a higher minimum amount is in dispute | ||
CMS adjusts the minimum amounts for levels 3 and 5 every year; your decision letter at each level tells you how to go to the next one.
Original Medicare appeals
- Read your Medicare Summary Notice. It lists denied claims and the reason. You have 120 days from the date you get it to appeal.
- Ask for a redetermination. Use form CMS-20027, or write to the contractor listed on the notice with your name, Medicare number, the item or service, the date of service and why you disagree. Attach any supporting records. The contractor usually decides within 60 days.
- Ask for reconsideration if needed. You have 180 days from the redetermination decision to ask a Qualified Independent Contractor (form CMS-20033), which usually decides within 60 days.
- Go further if needed. You have 60 days from the reconsideration decision to ask for an Administrative Law Judge hearing (form OMHA-100).
A short letter from your doctor explaining why the service was medically necessary is often the most useful evidence.
Medicare Advantage appeals
- Prior authorization: since January 1, 2026, plans must decide standard prior authorization requests within 7 calendar days and expedited requests within 72 hours.
- Appeal deadline: you, your representative or your doctor have 65 days from the date on the denial notice to ask the plan for a reconsideration.
- Plan decision times: 30 days for a standard service appeal, 60 days for a payment appeal, 7 days for a Part B drug appeal, and 72 hours for a fast appeal. The plan can extend some of these by up to 14 days if it tells you in writing.
- Level 2 is automatic: if the plan keeps its denial, it must send your case to an Independent Review Entity; you don't have to file again.
Part D drug appeals
- Coverage determination: your plan's first decision on whether it will cover a drug. You or your prescriber can ask for one. Plans decide within 72 hours, or 24 hours for a fast request.
- Exception: a coverage determination asking the plan to cover a drug that isn't on its formulary, to lower its cost-sharing tier, or to waive a rule such as step therapy or a quantity limit. Your prescriber must send a statement explaining the medical reason.
- Redetermination: if the plan says no, you have 65 days to appeal to the plan. It decides within 7 days (14 days for a payment request) or 72 hours for a fast appeal.
- Independent Review Entity: if the plan keeps its denial, you have 60 days to ask for an independent review, decided on the same timeframes.
Covered Part D drug costs are capped each year ($2,100 in 2026). See Medicare Part D in Oregon and the drug coverage guides.
Fast (expedited) appeals
If waiting for a standard decision could seriously jeopardize your life, health or ability to regain maximum function, ask for a fast appeal. Medicare Advantage and Part D plans must decide within 72 hours (24 hours for a fast Part D coverage request). If your doctor tells the plan that a fast decision is needed, the plan must give one.
Hospital discharge and services ending
In Oregon these fast-track reviews are handled by Acentra Health, the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for Region 10 (Alaska, Idaho, Oregon and Washington): 1-888-305-6759 (TTY 1-855-843-4776). The number is also on the notices you get.
- Hospital discharge: the hospital gives you the Important Message from Medicare about Your Rights. If you think you're being discharged too soon, call the QIO no later than your planned discharge day, before you leave. You can stay in the hospital while the QIO reviews your case and generally won't owe for those days beyond your usual costs. See how to appeal a hospital discharge in Oregon.
- Skilled nursing, home health, hospice or outpatient rehabilitation ending: you get a Notice of Medicare Non-Coverage at least two days before services end. Call the QIO by noon of the day before services are to end to ask for a fast review.
- Quality-of-care complaints: the QIO also reviews complaints about the quality of care you got from a Medicare provider.
IRMAA, penalties, OHP and complaints
- IRMAA: if your income dropped because of a life-changing event such as retirement, ask Social Security to use newer income with form SSA-44. To dispute the decision itself, ask Social Security for reconsideration. See how to appeal IRMAA after retiring.
- Part D late enrollment penalty: you can ask for a reconsideration using the form your plan sends with the penalty notice.
- OHP denials: if you also have the Oregon Health Plan and OHP or your CCO denies a service, the notice explains how to appeal and how to ask for a state hearing. OHP Client Services: 1-800-273-0557.
- Complaints (grievances): for problems that aren't about payment or coverage, such as poor customer service, file a grievance with your plan, or call 1-800-MEDICARE. For complaints about a Medigap company or an insurance agent, contact the Oregon Division of Financial Regulation (below). See how to file a complaint about an insurance agent in Oregon.
Reporting fraud
- 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048): report charges on your Medicare Summary Notice for care you didn't get.
- Senior Medicare Patrol Resource Center: 1-877-808-2468 (weekdays, 9:00 a.m. to 5:30 p.m. Eastern), which connects you with your state's SMP.
- HHS Office of Inspector General: 1-800-HHS-TIPS (1-800-447-8477) or oig.hhs.gov.
- OHP (Medicaid) fraud: the Oregon Health Authority's Office of Program Integrity for provider fraud, and the Oregon Department of Justice Medicaid Fraud Control Unit (971-673-1880).
Medicare cards don't need to be renewed, and Medicare won't call you uninvited to ask for your Medicare number. See how to report Medicare fraud in Oregon.
Where to get help in Oregon
- 1-800-MEDICARE: appeals forms, claim status and coverage questions.
- Acentra Health (BFCC-QIO): 1-888-305-6759, for discharge and services-ending reviews and quality complaints.
- Oregon Division of Financial Regulation, consumer advocates: 1-888-877-4894 or DFR.InsuranceHelp@oregon.gov, for Medigap and agent complaints.
- Social Security: 1-800-772-1213, for IRMAA and Part B enrollment issues.
- ODHS Aging and People with Disabilities (the state aging and disability agency): 1-855-673-2372, for Medicaid long-term care and in-home services.
- Your doctor's office: for a supporting letter or records, and for prescriber statements in drug appeals.
- Legal help: Legal Aid Services of Oregon and the Oregon Law Center serve people with low incomes, and Disability Rights Oregon helps people with disabilities.
A licensed insurance agent can explain how your plan's appeal process works and, if a plan keeps denying what you need, which plans to consider at Open Enrollment; you can request a call from a licensed insurance agent. See all Oregon Medicare resources and Medicare phone numbers in Oregon.
Tips that help
- Watch the deadline. If you miss it, you must give a good reason for filing late.
- Get your doctor's support. A specific letter about medical necessity is often the strongest evidence.
- Point to the rule. If your plan's Evidence of Coverage or a Medicare coverage rule covers the service, quote it.
- Keep records. Save every notice, send appeals in a way you can track, and note the date, time and name for each phone call.
- Name a representative. Form CMS-1696 lets a family member or someone else act for you in an appeal.
Related guides
Oregon Medicare resources
Agencies and phone numbers.
Medicare Part D in Oregon
Drug coverage and exceptions.
How do I appeal a Medicare denial in Oregon?
The short answer.
Sources
- Medicare.gov — Appeals in Original Medicare
- Medicare.gov — Appeals in Medicare health plans
- Medicare.gov — Appeals in a Medicare drug plan
- CMS — Improving prior authorization processes (CMS-0057-F decision timeframes)
- Medicare.gov — Medicare Summary Notice
- CMS — Beneficiary and Family Centered Care QIOs
- Medicare.gov — Reporting Medicare fraud and abuse
- SMP Resource Center
- Oregon Division of Financial Regulation — Contact us
- Oregon Health Authority — Report fraud
- Social Security — Form SSA-44, Medicare Income-Related Monthly Adjustment Amount: Life-Changing Event
Every question in this guide
- How can I help my parent with Medicare in Oregon?
- How do I appeal a hospital discharge in Oregon if I'm not ready to go home?
- How do I appeal a Medicare denial in Oregon?
- How do I file a complaint about a Medicare insurance agent in Oregon?
- How do I find a licensed insurance agent for Medicare in Oregon?
- How do I find Medicare doctors in Oregon?
- How do I report Medicare fraud in Oregon?
- What are the Medicare phone numbers for Oregon?
- Where is the Social Security office near me in Oregon?
Frequently asked questions
How long do I have to file a Medicare appeal?
With Original Medicare, 120 days from the date you get the Medicare Summary Notice that lists the denied item. With a Medicare Advantage or Part D plan, 65 days from the date on the plan's denial notice. Hospital and skilled nursing discharge appeals have much shorter deadlines, often by your discharge day or by noon the day before services end.
What is an expedited appeal?
A fast appeal you can ask for when waiting for a standard decision could seriously jeopardize your life, health or ability to regain maximum function. Medicare Advantage and Part D plans must decide within 72 hours; a fast Part D coverage request is decided within 24 hours. If your doctor supports the request, the plan must expedite it.
Can a Medicare Advantage plan require prior authorization?
Yes. Medicare Advantage plans can require approval before some services. Since January 1, 2026, plans must decide standard prior authorization requests within 7 calendar days and expedited requests within 72 hours. If a request is denied, you or your doctor can appeal within 65 days.
What can I do if my drug is not on my plan's formulary?
You or your prescriber can ask your Part D plan for an exception, a type of coverage determination, with a statement from your prescriber explaining why you need the drug. If the plan says no, you can ask for a redetermination within 65 days. You can also switch plans during Open Enrollment, October 15 to December 7.
What is a Medicare Summary Notice?
The statement Original Medicare mails every few months if you got Medicare-covered services, listing what was billed, what Medicare paid and what you may owe. It is not a bill. If you have a Medicare.gov account, you can get it electronically each month. Its back page explains how to appeal.
Someone called saying my Medicare card is expiring. Is that a scam?
Yes. Medicare will never call you uninvited to ask for personal information, and calls about a card expiring are a common scam. Hang up, don't give your Medicare number, and report it to 1-800-MEDICARE or the Senior Medicare Patrol Resource Center at 1-877-808-2468.
What does the Senior Medicare Patrol do?
Senior Medicare Patrols, funded by the federal Administration for Community Living, help people with Medicare prevent, spot and report fraud, errors and abuse. The national SMP Resource Center (1-877-808-2468) connects callers with their state's program.
Do I need a lawyer to appeal a Medicare denial?
No. Most people appeal on their own or with help from family or their doctor's office, and you can name someone to act for you with form CMS-1696. Some people hire an attorney at the higher levels, such as an Administrative Law Judge hearing.
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