Office of Medicare Hearings and Appeals (OMHA)

Level 1, Original Medicare (Parts A & B)

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Medicare contracts with private companies to process medical claims (bills) for health care items and services provided to Medicare beneficiaries. After a claim is sent to the appropriate contractor, the contractor must:

• Determine if the items and services on the claim are covered or reimbursable by Medicare;
• Calculate any amount that is payable by Medicare;
• Make the payments to health care provider(s) who furnished the items or services; and
• Notify you of its decision to pay or deny coverage or payment for specific items or services.

If you disagree with Medicare's decision on your claim, you have the right to file an appeal.

The first level of an appeal for ORIGINAL Medicare is called a redetermination.  A redetermination is performed by the same contractor that processed your Medicare claim.  However, the individual that performs the appeal is not the same individual that processed your claim.  The appeal is a new and independent review of your claim.

Your appeal rights are on the last page or back of the Medicare Summary Notice that is mailed to you from a contractor that processes claims for Medicare. The notice will also tell you why your claim was not paid and what appeal steps you can take.

You can request an appeal within 120 days from the date you received the Medicare Summary Notice. If you wish to file an appeal, follow the instructions on the Medicare Summary Notice.

For more information about filing a Level 1 appeal, visit the  "Appeals and Grievance" section of Medicare.gov.

If your Level 1 appeal was not decided in your favor, you may wish to file a Level 2 appeal. In Original Medicare (Parts A&B), a Level 2 appeal is called a QIC reconsideration.