The six fast-track appeal levels
Checked against the current rules on September 23, 2026.
An Original Medicare claim denial can move through up to six levels of review on the fast-track ladder. Most cases resolve at the first or second — but knowing the whole ladder helps you understand where your case actually is, and what's next if it keeps going.
Fast-track review — the QIO's initial decision
Decided by: Your state's BFCC-QIO (Beneficiary and Family-Centered Care Quality Improvement Organization).
By the deadline stated on your notice — see the fast-appeal page for the exact rule for your situation.42 CFR 405.1202
1 calendar day (observation, hospital discharge) or 72 hours (SNF/home health/hospice ending), once the QIO has what it needs.
Where to send it: By phone, to your state's BFCC-QIO — see the fast-appeal page for the number.
Reconsideration — after a termination or hospital-discharge decision
Decided by: A Qualified Independent Contractor (QIC) — C2C Innovative Solutions (eastern states) or Maximus (western/central states).
By noon, local time, the calendar day after the QIO's own determination notice.42 CFR 405.1204
72 hours, with a 14-day extension available at your own request.
Where to send it: By phone to the QIC for your state — see your case for the number.
Reconsideration — after an observation-status decision
Decided by: The same BFCC-QIO, reconsidering its own initial determination.
By noon, local time, the calendar day after the QIO's own determination notice.42 CFR 405.1212
2 calendar days (3 if your original request was untimely).
Where to send it: By phone to the same QIO that made the initial determination.
Administrative Law Judge (ALJ) hearing
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.42 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.
Medicare Appeals Council review
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.42 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.
Federal district court
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)).42 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.
Questions people ask
- Do I have to go through every level in order?
- Yes — each level is reached only after the one before it.
- What if I miss a deadline?
- Every level with a filing deadline allows a late filing for good cause — a serious illness, a family emergency, or not having received the notice, for example.
Sources — last checked September 23, 2026
- 42 CFR 405.1002as of September 23, 2026
- 42 CFR 405.1102as of September 23, 2026
- 42 CFR 405.1130as of September 23, 2026
- 42 CFR 405.1202as of September 23, 2026
- 42 CFR 405.1204as of September 23, 2026
- 42 CFR 405.1212as of September 23, 2026
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By CaseWhy Appeals editorial. See how this content is produced. Not legal advice. Not affiliated with or endorsed by Medicare, CMS, or any health plan. A product of CaseWhy LLC.
