BILLING REFERENCE

Medicare Appeal Levels (Fee-for-Service)

Medicare fee-for-service has five appeal levels, each with its own deciding body, deadline, and (for the higher levels) a minimum dollar amount in controversy. Unlike commercial timeframes, these are set in federal regulation and are exact. The amount-in-controversy thresholds for the ALJ and federal court levels are adjusted annually, so confirm the current-year figure before relying on it. This is the ladder for Part A and Part B claims; Medicare Advantage runs on a separate, plan-based appeals process.

Level	Decided by	Deadline to request	Notes
1. Redetermination	Medicare Administrative Contractor (MAC)	120 days from the initial remittance (Medicare Summary Notice)	First review by the contractor that processed the claim
2. Reconsideration	Qualified Independent Contractor (QIC)	180 days from the redetermination decision	Independent review; submit all evidence here
3. ALJ hearing	Administrative Law Judge (OMHA)	60 days from the reconsideration decision	Requires a minimum amount in controversy (adjusted annually)
4. Appeals Council review	Medicare Appeals Council (DAB)	60 days from the ALJ decision	Reviews the ALJ decision
5. Federal court review	U.S. District Court	60 days from the Appeals Council decision	Requires a higher minimum amount in controversy (adjusted annually)

What to do with this

Level 1 is the 120-day redetermination — the deadline most often missed because practices treat the first remit as final.
Build your strongest case at Levels 1 and 2; the reconsideration (QIC) is where the full evidentiary record should be complete.
Levels 3 and 5 have dollar thresholds that change every year — verify the current amount in controversy before assuming a claim qualifies.
This ladder is for fee-for-service. A Medicare Advantage denial follows the plan's own appeal process, not these five levels.

More billing references

Timely Filing Limits by Payer →Appeal Deadlines by Payer and Level →Healthy RCM Benchmarks →Denial Rate Benchmarks →CPT Modifier Quick Reference →CARC Group Codes (CO, PR, OA, PI) →Place of Service (POS) Codes Commonly Disputed →

Volari tracks each Medicare denial to the correct level and its exact deadline, and assembles the evidentiary record before the redetermination — so the winnable claims move up the ladder instead of expiring at Level 1.

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