Office of Medicare Hearings and Appeals (OMHA)

Appeals Involving Coverage of and Payment for Medicare Benefits

Most Medicare appeals concern either Medicare's coverage of or payment for medical services or items.  The entry point of the appeals process depends on the part of the Medicare program that covers the disputed benefit or whether the beneficiary is enrolled in a Medicare Advantage plan.  (See Understanding the Medicare Appeals Process for more information on the different parts of the Medicare program.)  For appeals involving coverage of and payment for Medicare benefits, there are three entry points to the appeals process:

• Medicare carrier or fiscal intermediary (currently under transition as Medicare Administrative Contractor) has a contract with CMS to process claims under Original Parts A and B of the Medicare program. The Medicare Contractor makes “initial determinations” and “redeterminations.”
• Medicare Advantage Plan under Part C of the Medicare program.  Medicare Advantages Plans make "organization determinations."
• Medicare Prescription Drug plan under Part D of the Medicare program.  Medicare prescription drug plans make "coverage determinations."

Each of these entities makes a decision about the coverage of and payment for medical services or items provided to a Medicare beneficiary.  The appeals processes for "Original Medicare" (Parts A and B), the Medicare Advantage program (Part C) and the Medicare Prescription Drug program (Part D) are described in other pages of this website.