Denials
Medicare appeal levels and deadlines for Part A and Part B claims
Medicare appeal levels and deadlines for original Medicare claims: five levels, filed within 120 days (redetermination by the Medicare Administrative Contractor), 180 days (reconsideration), then 60 days each for an Administrative Law Judge hearing, Medicare Appeals Council review and federal court. Each clock runs from receipt, presumed 5 days after the notice date. For requests filed in 2026 an ALJ hearing needs $200 in controversy and judicial review $1,960. This is general information, not legal advice. Review your payer contracts and the rules where you practice with your compliance advisor.
Published by OffshoreMeds. Facts last checked October 17, 2026. How we check our numbers.
The levels
The five levels, who decides and when to file
| Level | Who decides | File within | Decision period | Amount in controversy |
|---|---|---|---|---|
| Level: 1. Redetermination | Who decides: The Medicare Administrative Contractor (MAC) | File within: 120 days from receipt of the initial determination | Decision period: 60 days from the MAC's receipt of a timely request | Amount in controversy: None stated |
| Level: 2. Reconsideration | Who decides: A Qualified Independent Contractor (QIC) | File within: 180 days from receipt of the redetermination | Decision period: 60 days from the QIC's receipt; the appellant can then escalate to OMHA | Amount in controversy: None stated |
| Level: 3. ALJ hearing | Who decides: An Administrative Law Judge or attorney adjudicator at the Office of Medicare Hearings and Appeals (OMHA) | File within: 60 days from receipt of the reconsideration | Decision period: 90 days from receipt of the request, or 180 days if escalated from the QIC | Amount in controversy: $200 for requests filed in 2026 |
| Level: 4. Medicare Appeals Council | Who decides: The Medicare Appeals Council, which reviews the ALJ decision de novo | File within: 60 days from receipt of the ALJ decision | Decision period: 90 days from receipt of the request, or 180 days if escalated from OMHA | Amount in controversy: None stated |
| Level: 5. Federal district court | Who decides: A federal district judge | File within: 60 days from receipt of the Council decision | Decision period: Set by the court, not by the Part 405 rules | Amount in controversy: $1,960 for requests filed in 2026 |
The clock
How the deadlines are counted
- Each period runs from the date the party receives the notice. Receipt is presumed to be 5 calendar days after the date on the notice unless there is evidence to the contrary, so the window for a redetermination usually runs to about 125 days after the date on the initial determination (our arithmetic from the two figures).
- A request counts as filed on the date the contractor receives it, not the date it is mailed (42 CFR 405.942), and the QIC rule is the same (42 CFR 405.962).
- A late request can be accepted for good cause. It must be in writing and say why it was late, and the contractor looks at what kept the party from filing on time, whether the contractor’s own actions misled the party, and any physical, mental, educational or linguistic limitation. The same standards apply at the later levels (42 CFR 405.942(b)).
- If the QIC or OMHA does not decide within its period, the appellant can ask in writing to move up a level, and the QIC or OMHA then has five days to decide or forward the case file (42 CFR 405.970, 405.1016). After the Council’s own period the appellant can ask to move to federal court (42 CFR 405.1132).
- Evidence should be complete by the reconsideration. A provider or supplier that first offers evidence to the ALJ has to say why it was not given to the QIC, or the evidence can be excluded (42 CFR 405.1018).
- A billing company that files an appeal for a provider acts as an appointed representative, which needs a written, signed and dated appointment, valid for one year unless revoked (42 CFR 405.910).
Amounts
The amount in controversy: 2025, 2026 and 2027
| Requests filed in | ALJ hearing (US dollars) | Judicial review (US dollars) | Source |
|---|---|---|---|
| Requests filed in: 2025 | ALJ hearing (US dollars): 190 | Judicial review (US dollars): 1,900 | Source: Federal Register notice, September 27, 2024 |
| Requests filed in: 2026 | ALJ hearing (US dollars): 200 | Judicial review (US dollars): 1,960 | Source: 90 FR 55869, December 4, 2025 |
| Requests filed in: 2027, from January 1 | ALJ hearing (US dollars): 200 | Judicial review (US dollars): 2,000 | Source: 91 FR 58681, September 16, 2026 |
The amount follows a formula in 42 CFR 405.1006: a base amount raised by the medical-care component of the Consumer Price Index, published each year in the Federal Register. For a claim it is the amount charged, less what Medicare has paid and less the deductible and coinsurance that may be collected. For an overpayment it is the amount in the demand letter, and for an extrapolated overpayment the total estimated overpayment. Claims that a QIC has already reconsidered can be combined to reach the ALJ amount when the appellant asks within 60 days after receiving all of the reconsiderations and the claims involve similar or related services (one appellant) or common issues of law and fact (several). The notice, not a secondary summary, is the controlling source for each year’s figure.
Not an appeal
Reopening a claim is separate
A contractor can reopen an initial determination or redetermination within 1 year for any reason and within 4 years for good cause, and a party can ask on the same terms. A clerical error in an unfavorable determination can be corrected at any time. The decision whether to reopen cannot be appealed, and an issue cannot be reopened while a valid appeal of it is pending (42 CFR 405.980).
In practice
What this guide leaves to other pages
- The filing limit for the claim itself is a separate rule, covered in timely filing limits for medical claims.
- Medicare Advantage appeals follow 42 CFR Part 422, subpart M, and Part D drug appeals follow Part 423; the Part D clocks are on the prior authorization for drugs page.
- The work of building and tracking appeals is described on the denial management staff page.
- Not covered because the sources read do not say: success rates, processing times, how weekends and holidays count, how a limitation on liability affects the 120-day clock, and whether claims can be combined for judicial review.
This is general information, not legal advice. Review your payer contracts and the rules where you practice with your compliance advisor.
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One flat monthly fee per seat, never a percentage of collections. A Business Associate Agreement is signed before anyone touches protected health information. Clinical decisions stay with your US-licensed providers. See all OffshoreMeds services.
Related guides
- Denial management staff
Appeals, A/R follow-up and root-cause work, measured against published denial-rate benchmarks.
- Timely filing limits for medical claims
The federal caps, examples from Cigna, Aetna, Texas Medicaid and Illinois Medicaid, and how to find and track the limit that applies.
- Prior authorization for drugs
The Part D and Medicaid clocks that apply to drug requests, the electronic standards and what staff track.
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