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Office of Medicare Hearings and Appeals (OMHA)

Understanding the Appeals Process

There are four distinct health insurance programs within the Medicare program and each has its own appeals process.  These health insurance programs are referred to as "parts."  It is important that you know under what part of the Medicare program you received medical services or items in order to appeal a decision regarding those benefits. 

This is a flow chart that describes the appeals process. The chart starts by describing the appeals process for three different medicare plans, and continues through to level 5 of the appeals process.

In each part of the Medicare program, the Medicare contractor administering the program (usually an insurance company) makes a decision about your Medicare benefits.  In most cases, the decision is whether or not a medical service or item is covered and how much the Medicare program will pay for the service or item.  There are different names for these decisions depending on the part of the Medicare program covering the benefits. 

These are the names of the initial appealable decisions for each part of the Medicare program: 

  • Initial determination (Parts A & B “Original Medicare” which includes the Hospital Insurance program (Part A) and Supplementary Medical Insurance program (Part B));
  • Organization determination (Part C, the Medicare Advantage program); and
  • Coverage determination (Part D, the Medicare Prescription Drug program).

If you disagree with the initial determination, organization determination or coverage determination, you may choose to appeal.

If you are a Medicare beneficiary, you have certain guaranteed rights. One of these is the right to a fair process to appeal decisions about your health care coverage or payment. No matter what kind of Medicare you have, you may have the right to appeal these decisions.

You can appeal if:

  • A service or item you received isn’t covered, and you think it should be;
  • A service or item is denied, and you think it should be paid; and/or
  • You question the amount that Medicare paid.

You can also appeal other decisions of the Medicare program on non-medical issues. An example of such an issue is your eligibility for the Medicare program if your application to enroll in Medicare was denied. 

Description of the Different Parts of Medicare

Parts A & B:  Original Medicare

Parts A & B or “Original Medicare” includes Hospital Insurance (Part A) and Supplementary Medical Insurance (Part B).

Hospital insurance (Part A) helps pay for inpatient care in a hospital or skilled nursing facility (following a hospital stay), some home health care and hospice care.

Medical insurance (Part B) helps pay for doctors’ services and many other medical services and supplies that are not covered by hospital insurance.

Personal Medicare card which lists your plan type. This card was sent to all beneficiaries.

Part C: Medicare Advantage Program

Part C is the Medicare Advantage program.

Under the Medicare Advantage program (Part C), Medicare Advantage plans are available in many areas. Beneficiaries with Medicare Parts A and B can choose to receive all of their health care services through one of these Medicare Advantage plans under Part C.
Wallet containing private health insurance or HMO cards within it.

Part D: Medicare Prescription Drug Program

Part D is the Medicare Prescription Drug program.

Prescription drug coverage (Part D) helps pay for certain medications doctors prescribe for treatment.  Beneficiaries obtain prescription drugs through Medicare Prescription Drug Plans.

Prescription drugs

Please note that the Office of Medicare Hearings and Appeals is responsible only for the Level 3 claims appeals and certain Medicare entitlements and IRMAA appeals. OMHA is not responsible for levels 1, 2, 4, and 5 of the appeals process. OMHA provides additional information on other levels of appeals to help you understand the appeals process in a broad context.