The five appeal levels
| Level | Original Medicare | Medicare Advantage or Part D |
|---|---|---|
| 1 | Redetermination by the Medicare Administrative Contractor. File within 120 days of the Medicare Summary Notice; decision in about 60 days. | Reconsideration (Advantage) or redetermination (Part D) by your plan. File within 65 days of the denial notice. |
| 2 | Reconsideration by a Qualified Independent Contractor. File within 180 days. | Independent Review Entity. An Advantage plan that upholds its denial sends your case on automatically. |
| 3 | Hearing with the Office of Medicare Hearings and Appeals (an Administrative Law Judge), if the amount in dispute meets the minimum CMS sets each year. File within 60 days. | |
| 4 | Medicare Appeals Council review. File within 60 days. | |
| 5 | Federal district court, if the amount meets a higher yearly minimum. File within 60 days. | |
Each decision letter tells you how to go to the next level. Ask your doctor for records or a letter that supports your case before you file.
Fast appeals
- Hospital discharge. Call Acentra Health, the BFCC-QIO for Oregon, at 1-888-305-6759 (TTY 1-855-843-4776) no later than your planned discharge day. See how to appeal a hospital discharge.
- Skilled nursing, home health, hospice or rehab ending. Call the QIO by noon the day before services end, as your Notice of Medicare Non-Coverage explains.
- Medicare Advantage care you need now. Ask for a fast appeal; the plan must decide within 72 hours if waiting could seriously harm your health.
- Part D drugs. Ask for a fast coverage decision (24 hours) or fast appeal (72 hours), with a statement from your prescriber.
Who can help in Oregon
- 1-800-MEDICARE (1-800-633-4227; TTY 1-877-486-2048) can explain your notice and where to send an appeal.
- Your plan's member services number, on your card, for Advantage and Part D appeals.
- The Oregon Division of Financial Regulation's consumer advocates, 1-888-877-4894, for disputes with a Medigap company.
If a plan keeps denying care you need, you may be able to change plans during Open Enrollment (October 15 to December 7) or another enrollment period. You can request a call from a licensed insurance agent to compare plans from the companies they work with. Our Medicare appeals guide covers each step in more detail.
Related questions
How do I appeal a hospital discharge in Oregon?
Your rights before you leave.
How do I report Medicare fraud in Oregon?
Who to call about billing you don't recognize.
Medicare phone numbers for Oregon
Every number in one place.
Sources
- Medicare.gov — Appeals
- Medicare.gov — Appeals in Original Medicare
- Medicare.gov — Appeals in Medicare health plans
- Medicare.gov — Fast appeals
- CMS — Form CMS-1696, Appointment of Representative
- CMS — Beneficiary and Family Centered Care QIOs
More questions 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 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?
Part of the guide: Medicare Appeals in Oregon · All questions
Frequently asked questions
Do I have to pay for the service while I appeal?
For a claim already billed, you can appeal before paying what Medicare denied, but the provider may still bill you. For a hospital discharge appeal filed on time, you can stay while the QIO reviews and you don't pay for those days beyond usual deductibles and coinsurance.
How long does an appeal take?
Original Medicare's first two levels each take up to 60 days. A Medicare Advantage plan has 30 days for care you haven't received yet and 72 hours for a fast appeal. Part D plans decide fast requests within 24 to 72 hours.
Can someone appeal for me?
Yes. A family member, friend, lawyer or your doctor can help. To name a representative, use form CMS-1696 or a signed letter with the same information.
Medicare in your Oregon county
Plans, local agents and help, county by county: Multnomah · Washington · Clackamas · Lane · Marion · Jackson · Deschutes · Linn · Douglas · Yamhill · Benton · Polk · Josephine · Umatilla · Klamath · Coos · Columbia · Lincoln · Clatsop · Malheur · All 36 counties →
