The five claims-ladder appeal levels

Decided by: Your Medicare Administrative Contractor (MAC) — a different reviewer than the one who processed the original claim.

120 days from the date on the Medicare Summary Notice — 120 calendar days from when you receive it (42 CFR § 405.942(a)), with receipt presumed to be 5 days after the notice's own date unless shown otherwise.rule42 CFR 405.942

60 calendar days from when the MAC receives your timely request. Each time you submit new evidence after filing, that 60-day clock is extended by up to 14 more calendar days for that submission (42 CFR § 405.950(a), (b)(3)) — this can happen more than once.

Where to send it: Your Medicare Administrative Contractor — the address is printed on the Medicare Summary Notice itself.

Decided by: A Qualified Independent Contractor (QIC) — an outside reviewer, not your MAC.

180 days from the date on the MAC's redetermination notice — 180 calendar days from when you receive it (42 CFR § 405.962), with the same 5-day receipt presumption.rule42 CFR 405.962

60 calendar days from when the QIC receives your timely request (42 CFR § 405.970). If the QIC can't meet that deadline, it must offer you the chance to escalate straight to OMHA instead of waiting (42 CFR § 405.970(e)(2)) — CaseWhy Appeals tells you the moment that right opens up.

None automatically — if the QIC misses its own 60-day deadline, you have the right to ask to escalate directly to OMHA, but you have to actually ask; nothing forwards on its own the way a missed MAC deadline can.

Where to send it: The Qualified Independent Contractor named in the MAC's redetermination notice.

Decided by: An Administrative Law Judge or attorney adjudicator at the Office of Medicare Hearings and Appeals (OMHA).

60 days from receiving the QIC's or QIO's reconsideration decision (42 CFR § 405.1014), with the same 5-day receipt presumption.rule42 CFR 405.1002

90 calendar days from when OMHA receives your timely request (42 CFR § 405.1016) — 180 days if your case reached OMHA by escalation. If OMHA misses its own deadline, you may escalate to the Medicare Appeals Council instead of waiting (§ 405.1016(e)-(f)).

The dollar amount still in dispute must meet a yearly minimum set by the Secretary — $200 for 2026 — to qualify for an ALJ hearing. Several denied claims can be combined to reach it if they involve similar or related services (42 CFR § 405.1006(e)).

None — you must actively request a hearing; it does not happen automatically.

Where to send it: The entity named in the reconsideration decision notice.

Decided by: The Medicare Appeals Council, part of HHS's Departmental Appeals Board.

60 days from the ALJ's or attorney adjudicator's decision (42 CFR § 405.1102(a)), with the same 5-day receipt presumption.rule42 CFR 405.1102

90 calendar days from when the Council receives your timely request (42 CFR § 405.1100(c)) — 180 days for a case that reached the Council by escalation from OMHA.

None — you must actively request Council review.

Where to send it: The Departmental Appeals Board, following the instructions printed in the ALJ's decision.

Decided by: A judge in a United States district court.

60 days from the Council's decision (or from the ALJ's decision, if the Council declined to review it) (42 CFR § 405.1130), with the same 5-day receipt presumption (§ 405.1136(c)(2)).rule42 CFR 405.1130

Set by the court, the same as any federal civil case.

The dollar amount still in dispute must meet a yearly minimum set by the Secretary — $1,960 for 2026.

Where to send it: A United States district court, by filing a civil action under section 205(g) of the Social Security Act.