The Medicare claims ladder: MAC, QIC, OMHA, Council, court

Checked against the current rules on September 24, 2026.

A denied line on your Medicare Summary Notice isn't the final word — it starts a real, five-level review process, each level decided by a genuinely different reviewer than the one before it.

Source: 42 CFR Part 405, Subparts I & J — expedited determinations, retrospective patient-status appeals, the standard claims ladder, and ALJ/Council/court review.

Level 1 is a redetermination by your Medicare Administrative Contractor (MAC) — a different reviewer at the same contractor than whoever processed the original claim. File within 120 days of the MSN's own date; the MAC has 60 days to decide.42 CFR 405.94242 CFR 405.946

Level 2 is a reconsideration by a Qualified Independent Contractor (QIC) — a genuinely separate organization, not part of your MAC. File within 180 days of the MAC's redetermination; the QIC has 60 days to decide.42 CFR 405.96242 CFR 405.970

Level 3 is a hearing before an Administrative Law Judge (or attorney adjudicator) at the Office of Medicare Hearings and Appeals (OMHA) — but only if the dollar amount still in dispute meets a yearly minimum. File within 60 days; OMHA has 90 days to decide.42 CFR 405.101442 CFR 405.101642 CFR 405.1006

Level 4 is review by the Medicare Appeals Council, part of HHS's own Departmental Appeals Board. File within 60 days of the ALJ's decision; the Council has 90 days.42 CFR 405.110242 CFR 405.1100

Level 5 is federal district court — the final level, available only if the amount still in dispute meets its own, higher dollar minimum.42 CFR 405.113642 CFR 405.1130

Two real family protections most people never hear about

An unrepresented beneficiary isn't bound by the evidence-preclusion rules that apply to a provider, a supplier, or a beneficiary represented by one — you generally don't lose the right to add evidence later just because you didn't submit everything at the redetermination stage.42 CFR 405.96642 CFR 405.1028

The Medicare Appeals Council reviews every issue in an unrepresented beneficiary's case, not only the specific points raised in the request for review. A family member, guardian, or power of attorney doesn't count as a "representative" for this specific purpose — only a formally appointed one does.42 CFR 405.1112

Missing a deadline at any level doesn't automatically end the case — good cause for late filing is a real, intended part of the process, not a technicality to find a way around.42 CFR 405.942

Sources — last checked September 24, 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.