Your Medicare Appeal Rights (and How to Appoint a Representative)

If Medicare or a Medicare plan denies coverage or payment for something you believe should be covered, you have the legal right to appeal — and there is no cost to file. An appeal is your formal request to have that decision reviewed. Understanding the levels, the deadlines, and how to let someone act for you helps you use the process fully; outcomes depend on your specific facts and the reviewers' decisions.

What is a Medicare appeal, and how is it different from a grievance?

An appeal challenges a decision about *coverage or payment* — for a service, item, or prescription drug you think Medicare should cover, or an amount you think it should pay. A grievance is a *complaint about quality or service* — long wait times, poor communication, or how you were treated — and does not change a coverage decision. Use an appeal when you want a "no" reconsidered; use a grievance when you want to report a problem. The two follow separate tracks, and you can file both if your situation calls for it.

What are the appeal levels under Original Medicare?

Original Medicare (Part A and Part B) uses a five-level appeals process, and you move up only if the prior level does not resolve it in your favor. You typically first learn of a denial on your Medicare Summary Notice (MSN).

Levels 3 and 5 also require the amount in dispute to meet a minimum dollar threshold that Medicare sets and updates each year — confirm the current amount at Medicare.gov. Each decision notice explains where and how to take the next step.

How do appeals work in a Medicare Advantage or Part D plan?

If you are in a Medicare Advantage (Part C) plan or a Part D prescription drug plan, your appeal starts with the plan rather than with Original Medicare, but it still runs through five levels. You generally begin by asking the plan for a coverage determination, then request a reconsideration (Part C) or redetermination (Part D) if the answer is no — typically within 60 days. If the plan upholds the denial, the case moves to an Independent Review Entity, and from there to an Administrative Law Judge, the Medicare Appeals Council, and finally federal court, mirroring levels 3 through 5 above.

You can also request a fast (expedited) decision when waiting could seriously jeopardize your health — for example, a drug you need now or care that is about to end. Standard and expedited requests have different, shorter timeframes; the plan's denial notice states the exact deadlines that apply to you.

Are there special fast appeals when care is ending?

Yes — if you are told that hospital, skilled nursing, home health, or hospice care is ending and you disagree, you can request an immediate, independent review before that care stops. Hospital discharge notices (the "Important Message from Medicare") and notices ending other services explain how to contact the review organization named on the notice. Acting quickly, usually by the deadline printed on the notice, is what preserves your right to keep coverage during the review.

How do you appoint someone to handle an appeal for you?

You can name almost anyone — a family member, friend, attorney, or advocate — to act for you by completing Form CMS-1696, "Appointment of Representative." This is the official federal form that authorizes your representative to make requests, present evidence, obtain appeals information, and receive notices in connection with your claim, appeal, or grievance "wholly in your stead," and it acknowledges that your medical information may be shared with them.

The form has clear parts:

1. Section 1 — you (the person with Medicare) fill in your name and Medicare Number, then sign and date to make the appointment.
2. Section 2 — your chosen representative accepts the role, states their relationship to you (for example, "relative" or "attorney"), and signs.
3. Sections 3 and 4 — used only when a representative waives a fee or waives payment for the items or services at issue.

A signed appointment is generally valid for one year and remains in effect for the duration of that appeal. Send Form CMS-1696 to the same place you are sending the appeal, grievance, or request it relates to. Note that some representatives who charge a fee for higher-level appeals must have that fee approved, and providers representing you for their own services generally cannot charge you.

Where can you get the form and official help?

Download Form CMS-1696 and step-by-step appeal instructions directly from the government at Medicare.gov. For questions about your specific denial, deadlines, or where to mail documents, call 1-800-MEDICARE (1-800-633-4227), TTY 1-877-486-2048, or the number on your plan's denial notice. You have the right to receive Medicare information in an accessible format, such as large print, Braille, or audio.

As an independent Texas agency, we can help you understand these rights in plain English, but Medicare and your plan — not our agency — decide appeals. This article is educational only and is not legal advice.