Where do I start? With your notice
Every Medicare denial comes with a written notice that explains the decision, how to appeal and the deadline. Which notice you get depends on your coverage:
- Original Medicare: the Medicare Summary Notice (MSN), mailed every four months if you had services, or available sooner in your Medicare.gov account. It shows which claims were denied and where to send an appeal.
- Medicare Advantage plan: a written denial notice from the plan, and the Explanation of Benefits for payment decisions.
- Part D or a Medicare plan with drug coverage: a notice from the plan. If the pharmacy can't fill a prescription, ask the pharmacist how to contact your plan for a coverage decision.
Keep copies of everything, and ask your doctor for a letter explaining why you need the service or drug. You can name a family member or someone else to act for you with Medicare's Appointment of Representative form (CMS-1696); see helping a parent with Medicare.
What are the five levels in Original Medicare?
| Level | Who decides | Deadline to ask |
|---|---|---|
| 1. Redetermination | The Medicare Administrative Contractor that processed the claim | 120 days from the date you get the MSN; decision generally within 60 days |
| 2. Reconsideration | A Qualified Independent Contractor (QIC) | 180 days after the level 1 decision |
| 3. Hearing | The Office of Medicare Hearings and Appeals (an Administrative Law Judge hearing or a review of the record) | 60 days after the level 2 decision |
| 4. Appeals Council review | The Medicare Appeals Council | 60 days after the level 3 decision |
| 5. Judicial review | Federal district court | 60 days after the Appeals Council decision |
Levels 3 and 5 apply only if the amount in dispute is at least a minimum Medicare sets each year, and the level 5 minimum is much higher. You may be able to combine claims to reach it. Medicare.gov publishes the current amounts.
How do Medicare Advantage appeals work?
With a Medicare Advantage plan, the plan makes the first decisions, and the steps have different names:
- Organization determination. The plan decides whether it will cover a service or pay a claim, including prior authorization. If waiting could seriously harm your health, you or your doctor can ask for a fast decision.
- Reconsideration (level 1). If the plan says no, you, your representative or your doctor can appeal within 65 days of the date on the denial notice. The plan decides within 30 days for a service you haven't received, 60 days for a payment, 7 days for a Part B drug, or 72 hours for a fast appeal; it can take up to 14 more days in some cases and must tell you in writing.
- Independent Review Entity (level 2). If the plan keeps its denial, it must send your case automatically to an independent reviewer. You don't have to file anything.
- Levels 3 to 5. Same as Original Medicare: a hearing, the Medicare Appeals Council, then federal court, with the same yearly minimum amounts.
If you're in a MyCare Ohio plan for both Medicare and Medicaid, the plan uses one combined appeals process for both programs, and its notice explains your next steps. See MyCare Ohio.
How do Part D drug appeals work?
- Coverage determination. Ask your plan to cover a drug, including an exception (to cover a drug not on its list, waive a step-therapy or quantity rule, or lower your cost-sharing tier). Your prescriber's statement explaining the medical reason helps. If waiting could seriously harm your health, ask for a fast decision.
- Redetermination (level 1). If the plan says no, ask for a redetermination within 65 days of the date on the denial notice. The plan decides within 7 days (14 days for a payment request), or 72 hours for a fast appeal.
- Independent Review Entity (level 2). Unlike Medicare Advantage medical appeals, you must ask for this review yourself, within 60 days of the plan's decision.
- Levels 3 to 5. A hearing, the Medicare Appeals Council and federal court, with yearly minimum amounts for levels 3 and 5.
Tip: If drug costs are the problem rather than a denial, Part D's yearly out-of-pocket cap is $2,400 in 2027, and you may qualify for Extra Help or a Medicare Savings Program. See Extra Help in Ohio and our drug cost cap calculator.
What if my hospital stay or care is ending too soon?
When covered care is ending, a separate, faster process applies. In Ohio, these appeals go to Commence Health (formerly Livanta), the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for Ohio, at 1-888-524-9900 (TTY 711). The number is also on your notice; older notices that name Livanta still work.
Leaving the hospital
You should get the Important Message from Medicare within 2 days of admission and again before discharge. If you think you're being discharged too soon, call the BFCC-QIO no later than your planned discharge day. It decides within one day of getting the information it needs. If you ask on time, you can stay while it decides without paying for the extra days, other than usual deductibles or coinsurance.
Skilled nursing, home health, hospice
You should get a Notice of Medicare Non-Coverage at least 2 days before covered services end at a skilled nursing facility, from a home health agency or hospice, or at a comprehensive outpatient rehabilitation facility. To appeal, call the BFCC-QIO by noon of the day before the date on the notice.
The BFCC-QIO also reviews complaints about the quality of care you got from a doctor, hospital or other provider under Medicare. Step-by-step help: how do I appeal a hospital discharge in Ohio?
How do I appeal IRMAA (higher premiums based on income)?
If your income from two years earlier was above the first IRMAA limit ($109,000 for an individual or $218,000 for a married couple filing jointly, for 2026 premiums; CMS publishes the 2027 limits each fall), Social Security adds an income-related amount to your Part B and Part D premiums. The brackets are cliffs: one dollar over a limit raises the whole amount. Social Security, not Medicare, decides this, and there are two ways to challenge it:
- Life-changing event (Form SSA-44). If your income dropped because of marriage, divorce, the death of a spouse, stopping or reducing work, or the loss of a pension or income-producing property, ask for a new decision based on a more recent year's income. This is common in the first years after retiring from an Ohio public employer or a private job.
- Reconsideration. If the tax information Social Security used is wrong, ask for a reconsideration within 60 days of receiving the notice.
Estimate your bracket with our IRMAA calculator, and call Social Security at 1-800-772-1213 (TTY 1-800-325-0778).
How do Ohio Medicaid appeals work?
If you have both Medicare and Ohio Medicaid, each program has its own appeals. Medicare decisions follow the steps above. Ohio Medicaid decisions go to a state hearing run by the Ohio Department of Job and Family Services (ODJFS) Bureau of State Hearings:
- Read the notice. A notice from your county Job and Family Services office or the Ohio Department of Medicaid explains the decision and your hearing rights, such as a denied application, a reduction in benefits or a level-of-care decision for waiver services.
- If a MyCare Ohio plan denied a service, appeal to the plan first. Ohio's rule gives you 60 calendar days from the date of the plan's notice to appeal, by phone or in writing; a phone appeal is confirmed in writing (OAC 5160-58-08.4).
- Ask for a state hearing within 90 days. For a county or state decision, the 90 days start the day after the notice was mailed. After a MyCare plan's appeal decision, you have 90 days from the date it was mailed (OAC 5101:6-3-02). Call 1-866-635-3748 or request a hearing online at secure.jfs.ohio.gov.
Ohio's rule says no agency or plan may limit or discourage your request for a hearing. Questions about a Medicaid plan go to the Ohio Medicaid Consumer Hotline, 1-800-324-8680. See Ohio Medicaid and Medicare.
What about complaints that aren't appeals?
If your problem isn't a coverage or payment decision, such as long waits, trouble reaching customer service or how you were treated, file a grievance with your Medicare Advantage or Part D plan; your plan's Evidence of Coverage explains how and by when. You can also tell Medicare about a problem with a plan at 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048) or with the complaint form on Medicare.gov.
When should I contact the Ohio Department of Insurance?
The Ohio Department of Insurance (ODI) regulates insurance companies and licenses agents in Ohio. It can't change a Medicare coverage decision. Its Consumer Services Division takes complaints about insurance companies and agents, including Medicare supplement (Medigap) insurers, and ODI asks you to contact the company first. Call 1-800-686-1526 or use ODI's online complaint center. See how to file a complaint about an insurance agent in Ohio.
When an appeal isn't the answer
If a plan keeps denying a drug or service you need, or a doctor you rely on leaves its network, it may make sense to change plans during an enrollment period you qualify for. A licensed insurance agent who works with Benefits Life can explain plans from the companies they work with and when you can switch, at no cost to you; you can request a call from a licensed insurance agent. For the appeal itself, follow the instructions on your notice and call 1-800-MEDICARE with questions. Suspicious charges? See Medicare fraud in Ohio.
Sources
- Medicare.gov — Appeals in Original Medicare
- Medicare.gov — Appeals in Medicare health plans
- Medicare.gov — Appeals in Medicare drug plans
- Medicare.gov — Fast appeals
- Medicare.gov — Medicare Summary Notice
- CMS — Beneficiary and Family Centered Care QIOs
- Commence Health — Ohio BFCC-QIO fact sheet (PDF)
- Social Security — Request to lower an IRMAA
- Social Security — Form SSA-44, life-changing event (PDF)
- Ohio Administrative Code 5101:6-3-02 — State hearings: time limits
- Ohio Administrative Code 5160-58-08.4 — MyCare Ohio plan appeals
- Ohio Department of Insurance — Consumer complaint information
Frequently asked questions
How long do I have to file a Medicare appeal?
For Original Medicare, you have 120 days from the date you get your Medicare Summary Notice. For a Medicare Advantage or Part D plan denial, you have 65 days from the date on the plan's notice. Later levels generally must be requested within 60 days, except the second Original Medicare level, which allows 180 days.
What is a Medicare Summary Notice?
The statement Original Medicare mails every four months if you had services, also available sooner in your Medicare.gov account. It lists what providers billed, what Medicare paid and what you may owe, and it explains how to appeal any denied claim. It isn't a bill.
Who is the Medicare quality improvement organization for Ohio?
Commence Health, formerly called Livanta, is the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for Ohio and the rest of Medicare Region 5. Call 1-888-524-9900 (TTY 711) for fast appeals of hospital discharges and other services ending, and for quality-of-care complaints.
Can the Ohio Department of Insurance overturn a Medicare denial?
No. Medicare coverage decisions follow the federal appeals process. The Ohio Department of Insurance takes complaints about insurance companies and agents, including Medigap insurers, at 1-800-686-1526, but it can't change a Medicare decision.
How do I appeal an Ohio Medicaid decision?
Ask for a state hearing with the Ohio Department of Job and Family Services within 90 days of the date the notice was mailed: call 1-866-635-3748 or request it online. If a MyCare Ohio plan denied a service, appeal to the plan first, within 60 days of its notice; you then have 90 days from the plan's appeal decision to ask for a state hearing.
Medicare in your Ohio county
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