The Appeals Process
OMHA is responsible for Level 3 claims appeals. The entry point of the appeals process depends on the part of the Medicare program that covers the disputed benefit or whether the beneficiary is enrolled in a Medicare Advantage plan.
There are five levels in the Medicare claims appeal process:
- Level 1: Your Health Plan. If you disagree with a Medicare coverage decision, you may request your health plan to redetermine your claim.
- Level 2: An Independent Organization. If you disagree with the decision in Level 1, you may request a reconsideration by an independent organization.
- Level 3: Office of Medicare Hearings and Appeals (OMHA). If you disagree with the Level 2 decision or dismissal, you may request that an OMHA adjudicator review the action.
- Level 4: The Medicare Appeals Council. If you disagree with the OMHA adjudicator's decision, you may request the Medicare Appeals Council review the decision.
- Level 5: Federal Court. If you disagree with the Medicare Appeals Council decision, you may seek a review of your claim in Federal District Court.
If you were told you are not eligible for Medicare, see Entitlement Appeals for guidance.
If you think your Part B Premium rate should be lowered, see Part B Premium Appeals for guidance.
Entities Responsible for Medicare Appeals by Level and Medicare Part
| Level of the Appeals Process | Medicare Parts A and B | Medicare Part C | Medicare Part D |
|---|---|---|---|
| Level 1 |
Medicare Contractor |
Medicare Advantage Plan | Medicare Prescription Drug Plan |
| Level 2 | QIC | Independent Review Entity | Independent Review Entity |
| Level 3 |
Office of Medicare Hearings and Appeals |
Office of Medicare Hearings and Appeals |
Office of Medicare Hearings and Appeals |
| Level 4 | Medicare Appeals Council | Medicare Appeals Council | Medicare Appeals Council |
| Level 5 | Federal Court | Federal Court | Federal Court |
Medicare Contractor Note: In each part of the Medicare program, the Medicare contractor administering the program (usually an insurance company) makes a decision about your Medicare benefits. In most cases, the decision is whether or not a medical service or item is covered and how much the Medicare program will pay for the service or item. There are different names for these decisions depending on the part of the Medicare program covering the benefits.
