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Original Medicare: Decisions, Appeals, and Noncoverage Notices

Adapted from Medicare Appeals, Centers for Medicare & Medicaid Services. The selected guidance concerns Medicare coverage and payment, not a recommendation for medical treatment. Numbered page references below refer to the linked source publication.

Coverage can depend on medical necessity, the setting, provider participation, and your plan’s rules. Use the cited publication for the full conditions and check the plan year when comparing costs or enrollment choices.

File an appeal in Original Medicare

Original Medicare includes Medicare Part A (Hospital Insurance) and Medicare Part B (Medical Insurance). Everyone with Original Medicare who gets covered services will get a “Medicare Summary Notice” (MSN) in the mail at least every 6 months. If you want to get electronic MSNs, log in (or create) your secure Medicare account at Medicare.gov/account/login and go to account settings to sign up for electronic MSNs. If you sign up for eletronic MSNs, you’ll get an email with a link to your MSN for any month you have a processed claim instead of waiting for a paper copy.

Your MSN shows:

  • All items and services that providers and suppliers billed to Medicare during the 6-month period
  • What Medicare paid
  • What you may owe the provider or supplier
  • If Medicare has approved, or fully or partially denied, your medical claim (this is the initial determination, and it’s made by the Medicare Administrative Contractor (MAC), which processes Medicare claims)

Read your MSN carefully. If you disagree with a Medicare coverage or payment decision, you can appeal the decision. Your MSN has information on how to file an appeal.

If you decide to file an appeal, ask your doctor, other health care provider, or supplier for any information that may help your case. Keep a copy of everything you send to Medicare as part of your appeal.

Contact your provider or supplier if an expected item or service is missing on your MSN, or you aren’t sure if Medicare was billed for the items and services you got. Ask them for an itemized statement that lists all of the items and services they billed to Medicare.

Note: Your provider has up to one year from the date you got an item or service to submit a claim.

What’s the appeals process for Original Medicare?

There are 5 levels of appeal in Original Medicare. If you disagree with the decision made at any level of the process, you can usually go to the next level. At each level you’ll get a decision letter with instructions on how to move to the next level. The 5 levels are:

Level 1: Redetermination by the MAC Level 2: Reconsideration by a Qualified Independent Contractor (QIC) Level 3: Decision by the Office of Medicare Hearings and Appeals (OMHA) Level 4: Review by the Medicare Appeals Council (Appeals Council) Level 5: Judicial Review by a Federal District Court

Level 1: Redetermination by the MAC

The first level of appeal in Original Medicare is called a redetermination.

Start your appeal by looking at your MSN. You must file your appeal by the date listed in your MSN. If you miss the deadline for appealing, you may still file an appeal and get a decision if you can show good cause for missing the deadline (for example, if you have a disability, illness, or accident that delayed you from filing your appeal by the deadline).

How do I file a redetermination?

Read your MSN carefully, and follow the appeal instructions:

  • Circle the item(s) and/or service(s) you wish to appeal on a copy of your MSN.
  • Explain in writing on your MSN or a separate piece of paper why you disagree with the initial determination.
  • Include your name, phone number, and Medicare Number.
  • Include any other information you have about your appeal. You can ask your provider for any information that may help your case. Write your Medicare Number on all documents you submit with your appeal request.
  • Mail your documents to the Medicare Claims office address listed in Step 7 on the last page of your MSN.

Or you can fill out a “Medicare Redetermination Request” form (CMS Form number 20027).

  • To get a copy, visit CMS.gov/cmsforms/downloads/cms20027.pdf, or call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
  • Include any other information you have about your appeal. You can ask your provider for any information that may help your case. Write your Medicare Number on all documents you submit with your appeal request.
  • Mail your documentation to the Medicare Claims office address listed in Step 7 on the last page of your MSN.

Or send a written request to the MAC. The company’s address is listed on your MSN. Your request must include:

  • Your name and Medicare Number.
  • List the specific items and/or services and dates you’re filing an appeal about. You can also circle the items and/or services you wish to appeal on a copy of your MSN.
  • Why you think the items and/or services should be covered.
  • If you’ve appointed a representative, a copy of the “Appointment of Representative” form or any written instrument that has the required elements. For more information on appointing a representative, go to page 3.
  • Any other information that may help your case.
  • Mail your documents to the Medicare Claims office address listed in Step 7 on the last page of your MSN.

Keep a copy of everything you send to Medicare as part of your appeal. You’ll generally get a decision from the MAC (either in a letter or an MSN) within 60 days after they get your appeal.

Medicare contracts with the MAC to review your appeal and make a decision. The people at the MAC who review and decide on your appeal are separate from the people who made the original coverage or payment decision.

You can send more information or evidence to the MAC after filing your redetermination request, but it may take longer than 60 days for the MAC to make a decision. The MAC will get an extra 14 calendar days to make a decision each time you send them more information or evidence.

After you file a redetermination

  • If the MAC decides that Medicare will cover the item(s) or service(s) you appealed: Your next MSN will show the decision.
  • If the MAC decides that Medicare won’t cover the appealed item(s) or service(s): You’ll generally get a decision letter from the MAC within 60 days.

If you disagree with the MAC’s decision:

You have 180 days after you get the MAC’s decision letter or an MSN to ask for a Level 2 appeal, called a “Reconsideration” by a Qualified Independent Contractor (QIC).

Level 2: Qualified Independent Contractor (QIC) Reconsideration

A QIC is an independent contractor that didn’t take part in the Level 1 decision. The QIC will review your request for a reconsideration and make a decision. Your request should clearly explain why you disagree with the redetermination decision from Level 1. It’s helpful to send a copy of the “Medicare Redetermination Notice” with your request for a reconsideration to the QIC.

How do I ask for a QIC reconsideration?

To ask for a reconsideration, follow the directions on the “Medicare Redetermination Notice” you got in Level 1. You must send your request to the QIC’s address listed on the “Medicare Redetermination Notice.” You can ask for a reconsideration in one of these ways:

  • Fill out a “Medicare Reconsideration Request” form, which is included with the “Medicare Redetermination Notice.”
  • You can also get a copy of this form by visiting CMS.gov/cmsforms/downloads/ cms20033.pdf, or calling 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
  • Send a written request that includes:
  • Your name and Medicare Number.
  • The specific item(s) and/or service(s) you’re requesting a reconsideration for and the specific date(s) of service. You can find this information in your “Medicare Redetermination Notice.”
  • The name of the MAC that made the redetermination, which you can find on your MSN and on the “Medicare Redetermination Notice.”
  • An explanation of why you disagree with the redetermination decision, and any evidence that might help make your appeal stronger.
  • The name of your representative, if you’ve appointed one. For more information on appointing a representative, go to section 2.
  • Mail your request with any additional documents to the QIC’s address listed on the “Medicare Redetermination Notice”.

No matter how you choose to ask for a reconsideration, you should clearly explain why you disagree with the redetermination decision from Level 1. Send a copy of the “Medicare Redetermination Notice” with your request for a reconsideration to the QIC. Information you submitted at Level 1 will be sent to the QIC to review. You can also send the QIC any more information that may help your case. If you send them information or evidence after your reconsideration request has been filed, it may take longer for the QIC to make a decision. Keep a copy of everything you send to Medicare as part of your appeal.

In most cases, the QIC will send you a written reconsideration decision about 60 days after the QIC gets your appeal request (with exceptions for extensions if you send in more evidence or file late). If the QIC is unable to complete its reconsideration in 60 days, you may ask for your case to move to the next level of appeal. If this happens, the QIC will send you a notice that explains your options: (1) to wait for the QIC to issue a decision, or (2) to send your appeal to the Office of Medicare Hearings and Appeals (OMHA). If you choose to send your appeal to OMHA, a written request must be filed with the QIC. The QIC can help you with what’s needed for this request.

If you disagree with the reconsideration decision in Level 2, you have 60 days after you get the QIC reconsideration decision letter to ask for a decision by OMHA, which is Level 3.

Level 3: Decision by the Office of Medicare Hearings and Appeals (OMHA)

If you aren’t satisfied with the QIC reconsideration decision, you can ask OMHA for a hearing before an Administrative Law Judge (ALJ) or, in certain circumstances, a review of your appeal record by an ALJ or attorney adjudicator.

A hearing before an ALJ allows you to present your appeal to a new person who will independently review the facts of your appeal and listen to your testimony before making a decision. An ALJ hearing is usually held by phone or video-teleconference, but can be held in person if the ALJ finds that you have a good reason.

You can also ask OMHA to make a decision without holding a hearing (based only on the information that’s in your appeal record). If you do this, either an ALJ or an attorney adjudicator will review the information in your appeal record and issue a decision. The ALJ or attorney adjudicator may also issue a decision without holding a hearing if, for example, information in your appeal record supports a decision that’s fully in your favor.

To get a hearing or review by OMHA, the amount of your case must meet a minimum dollar amount. The minimum dollar amount for 2026 is $200. The QIC reconsideration decision letter may include a statement that tells you if your case is estimated to meet the minimum dollar amount. However, it’s up to the ALJ to make the final decision. You may be able to combine claims to meet the minimum dollar amount.

How do I ask for an appeal by an Administrative Law Judge (ALJ)?

Follow the directions on the QIC reconsideration decision letter you got from the QIC in Level 2 to ask OMHA for a hearing before an ALJ. You must send your request to the OMHA Central Operations. The address is listed in the QIC’s reconsideration notice. You or your representative can ask for a hearing in one of these ways:

  • Fill out a “Request for Administrative Law Judge Hearing or Review of Dismissal” form (OMHA-100), which is included with the QIC reconsideration decision letter. You can also get a copy by visiting HHS.gov/about/agencies/omha/filing-an-appeal/forms, or calling 1-800-MEDICARE (1-800-633-4227).
  • Send a written request that includes:
  • Your name, address, phone number, and Medicare Number. If you’ve appointed a representative, include their name, address, and phone number.
  • The appeal number included on the QIC reconsideration decision, if any.
  • The dates of service for the items or services you’re appealing. Your MSN or QIC reconsideration decision letter will have this information.
  • Why you disagree with the reconsideration decision you’re appealing.
  • Any information that may help your case. If you can’t include this information with your request, include a statement explaining what you plan to submit and when you’ll submit it.

How do I ask for a review of my case without a hearing?

You can ask OMHA to make a decision without holding a hearing based only on the information in your appeal record. To do this, include one of these in your appeal request to OMHA:

  • The “Waiver of Right to an Administrative Law Judge (ALJ) Hearing” form (Form OMHA-104). You can get a copy by visiting HHS.gov/about/agencies/omha/filing-an-appeal/forms.
  • A written request stating you don’t wish to appear before an ALJ at a hearing (including a hearing held by phone or video-teleconference), and why you want to waive the hearing.

Even if you want to waive the ALJ hearing, a hearing may still be held by an ALJ if the other parties in your case (for example, your provider) don’t also waive the ALJ hearing, or if the ALJ believes a hearing is necessary to decide your case.

If you have asked OMHA for a decision without a hearing, but the ALJ decides a hearing is necessary, the ALJ will let you know when the hearing will be. If no hearing is held, either an ALJ or attorney adjudicator will review the information in your appeal record and issue a decision.

Keep a copy of everything you send to Medicare as part of your appeal. For more information about the OMHA decision process, visit HHS.gov/about/agencies/omha/ filing-an-appeal/coverage-and-claims-appeals. If you need help filing an appeal with an ALJ, call 1-800-MEDICARE.

If the ALJ doesn’t issue a timely decision, you may ask OMHA to move the case to the next level of appeal by sending a request to OMHA at the address listed on the QIC reconsideration notice.

If you disagree with OMHA’s decision, you may ask for a review at the next level of appeal by the Medicare Appeals Council. You have 60 days after you get OMHA’s decision to ask for an appeal at level 4.

Level 4: Review by the Medicare Appeals Council

You can ask for the Medicare Appeals Council to review your case, regardless of the dollar amount.

How do I ask for a review by the Medicare Appeals Council?

To ask for a Level 4 appeal, follow the directions in the OMHA’s hearing decision you got in the Level 3 appeal.

You can ask for a review by the Medicare Appeals Council in 1 of 2 ways:

  • Fill out a “Request for Review of an Administrative Law Judge (ALJ) Medicare Decision/Dismissal” form (DAB-101). To get a copy, visit HHS.gov/about/agencies/ dab/different-appeals-at-dab/appeals-to-council/form, or call 1-800-MEDICARE to ask for a copy.
  • Send a written request to the Medicare Appeals Council that includes:
  • Your name and Medicare Number. If you’ve appointed a representative, include their name.
  • The specific item(s) and/or service(s) and the specific dates of service you’re appealing. Check your MSN or your OMHA decision for this information.
  • A statement identifying the parts of OMHA’s decision you disagree with and an explanation of why you disagree. Send a copy of your request to your provider.
  • The date of OMHA’s decision.
  • If you’re asking that your case be moved from OMHA to the Medicare Appeals Council because OMHA hasn’t issued a timely decision, send your request to OMHA at the address listed on the QIC’s reconsideration notice or, the OMHA office where the request for hearing or review is pending (if you know that your case was assigned to an OMHA adjudicator).

Keep a copy of everything you send to Medicare as part of your appeal. For more information about the Appeals Council review process, visit HHS.gov/about/agencies/ omha/the-appeals-process/level-4/index.html. If you need help filing a request for Medicare Appeals Council review, call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

You can request judicial review in Federal district court (Level 5) if:

  • The amount of your case meets a minimum dollar amount. For 2026, the minimum dollar amount is $1,960. You may be able to combine claims to meet this dollar amount.

AND

  • The Medicare Appeals Council doesn’t issue a timely decision.

OR

  • You disagree with the Medicare Appeals Council’s decision in Level 4.

You have 60 days after you get the Appeals Council’s decision or notice to ask for judicial review by a federal district court.

Level 5: Judicial Review in Federal District Court

How do I ask for a judicial review?

Follow the directions in the Medicare Appeals Council’s letter you got in Level 4 to file an appeal in Federal District Court.

For more information on the appeals process

  • Visit Medicare.gov/appeals.
  • Call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.
  • Visit Medicare.gov/basics/forms-publications-mailings/forms/appeals for appeals forms.
  • Call your State Health Insurance Assistance Program (SHIP) for free, personalized health insurance counseling, including help with appeals. To get the phone number for the SHIP in your state, visit shiphelp.org, or call 1-800-MEDICARE.

What’s an “Advance Beneficiary Notice of Non-coverage” (ABN)?

If you have Original Medicare and your doctor, other health care provider, or supplier thinks that Medicare probably (or certainly) won’t pay for items or services, he or she may give you a written notice called an ABN (Form CMS-R-131).

The ABN lists the items or services that Medicare isn’t expected to pay for, an estimate of the costs for the items and services, and the reasons why Medicare may not pay. The ABN gives you information to make an informed choice about whether to get items or services, understanding that you may have to pay for them.

You’ll be asked to choose an option box and sign the notice to say that you read and understood it. You must choose one of these options:

  • Option 1—You want the items or services that Medicare may not pay for. Your provider or supplier may ask you to pay for them now, but you also want your provider or supplier to submit a claim to Medicare for the items or services.

If Medicare denies payment of the claim, you’re responsible for paying, but you can appeal the denied claim to Medicare. If Medicare does pay, the provider or supplier will refund payments you made (minus the copayments and deductibles you paid).

  • Option 2—You want the items or services that Medicare may not pay for, but you don’t want your provider or supplier to submit a claim to Medicare. You may be asked to pay for the items or services now, but because you asked your provider or supplier not to submit a claim to Medicare, you can’t file an appeal.
  • Option 3—You don’t want the items or services that Medicare may not pay for, and you aren’t responsible for any payments. A claim isn’t submitted to Medicare, and you can’t file an appeal.

An ABN isn’t an official denial of coverage by Medicare. If payment is denied when a claim is submitted, you have the right to file an appeal.

Other types of Advance Notices of Non-coverage

  • “Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage” A skilled nursing facility will issue you a “Skilled Nursing Facility Advance Beneficiary Notice of Noncoverage” (Form CMS-10055) if there’s reason to believe that Medicare may not cover or continue to cover your care or stay because it isn’t reasonable and necessary, or is considered non-medical long-term care.

If you choose to get services that Medicare Part A (Hospital insurance) may not cover, you don’t have to pay for these services until a claim is submitted and Medicare officially denies payment. However, while the claim is processed, you have to continue paying costs that you would normally have to pay, like the daily coinsurance and costs for services and supplies Medicare generally doesn’t cover.

The skilled nursing facility may use the “Skilled Nursing Facility Advance Beneficiary Notice of Non-coverage” and collect money from you now for Medicare Part B (Medical insurance) items or services. If Medicare pays, the skilled nursing facility will refund any payments you made, except copayments or deductibles.

  • “Hospital Issued Notice of Non-coverage” (HINN) Hospitals use a “Hospital Issued Notice of Non-coverage” when Medicare may not cover all or part of your inpatient hospital care, or, in some cases, related Part B services. This notice will tell you why the hospital thinks Medicare won’t pay, and what you may have to pay if you keep getting these services. There are 4 types of “Hospital Issued Notices of Non-coverage:”
  • Preadmission/Admission
  • Hospital Requested Review
  • Noncovered Services During Covered Stay
  • Noncovered Continued Stay

Services & supplies Medicare generally doesn’t cover

Doctors, other health care providers, and suppliers don’t have to (but still may) give you an ABN for services that Medicare generally doesn’t cover, like:

  • Dental services
  • Hearing aids
  • Routine eye exams
  • Routine foot care

What notices do home health agencies give?

Home health agencies are required to give people with Original Medicare written notices including:

“Home Health Change of Care Notice”

Your home health agency should give you this written notice when your home health plan of care is changing because of one of these:

  • The home health agency makes a business decision to reduce or stop giving you some or all of your home health services or supplies
  • Your doctor changed your orders, which may reduce or stop giving you certain home health services or supplies

The “Home Health Change of Care Notice” lists the services or supplies that will be changed, and it gives you instructions on what you can do if you don’t agree with the change.

The home health agency isn’t required to give you a “Home Health Change of Care Notice” when it issues the “Notice of Medicare Non-Coverage.”

“Advance Beneficiary Notice of Non-coverage”

When a home health agency believes that Medicare may not pay for certain home health items and services or all of your home health care, the agency should give you an “Advance Beneficiary Notice of Non-coverage” (ABN). Go to page 13 for more information on the ABN.

Home health agencies are required to give you an ABN if your care is reduced or stopped, or before you get any items or services that Medicare may not pay for because:

  • They’re not considered medically reasonable and necessary
  • The care is non-medical long-term care
  • You aren’t confined to your home
  • You don’t need intermittent skilled nursing care

“Notice of Medicare Non-Coverage”

Your home health agency will give you this notice when all of your Medicare-covered services are ending. This notice will tell you when the services will end and how to appeal if you think the services are ending too soon. This notice also tells you how to contact your Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) to ask for a fast appeal. If you don’t get this notice, ask for it. For more information your BFCC-QIO visit CMS.gov/medicare/quality/quality-improvement-organizations/family-centered-care.

If you decide to ask for a fast appeal, you should call the BFCC-QIO within the timeframe listed on the notice. After you ask for a fast appeal, you’ll get a second notice with more information about why your care is ending. The BFCC-QIO may ask you about your care. To help your case, ask your doctor for information to submit to the BFCC-QIO.

“Detailed Explanation of Non-Coverage”

Your home health agency will give you this notice when it’s informed by the BFCC-QIO that you’ve asked for a BFCC-QIO review of your case. The notice will explain why your home health agency believes that Medicare will no longer pay for your home health care.

Source and further reading

Medicare Appeals — Centers for Medicare & Medicaid Services. Public domain U.S. government educational material, accessed October 28, 2026. Fynoptic has selected sections, removed print navigation, and reformatted the text for this guide. The agency does not endorse Fynoptic.

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