Where do I start? With your notice
Every Medicare denial comes with a written notice that explains the decision, how to appeal and the deadline. Which notice you get depends on your coverage:
- Original Medicare: the Medicare Summary Notice (MSN), mailed every four months if you had services, or available sooner in your Medicare.gov account. It shows which claims were denied and where to send an appeal.
- Medicare Advantage plan: a written denial notice from the plan, and the Explanation of Benefits for payment decisions.
- Part D or a Medicare plan with drug coverage: a notice from the plan. If the pharmacy can't fill a prescription, ask the pharmacist how to contact your plan for a coverage decision.
Keep copies of everything, and ask your doctor for a letter explaining why you need the service or drug. You can name a family member or someone else to act for you with Medicare's Appointment of Representative form (CMS-1696); see helping a parent with Medicare.
What are the five levels in Original Medicare?
| Level | Who decides | Deadline to ask |
|---|---|---|
| 1. Redetermination | The Medicare Administrative Contractor that processed the claim | 120 days from the date you get the MSN; decision generally within 60 days |
| 2. Reconsideration | A Qualified Independent Contractor (QIC) | 180 days after the level 1 decision |
| 3. Hearing | The Office of Medicare Hearings and Appeals (an Administrative Law Judge hearing or a review of the record) | 60 days after the level 2 decision |
| 4. Appeals Council review | The Medicare Appeals Council | 60 days after the level 3 decision |
| 5. Judicial review | Federal district court | 60 days after the Appeals Council decision |
Levels 3 and 5 apply only if the amount in dispute is at least a minimum Medicare sets each year, and the level 5 minimum is much higher. You may be able to combine claims to reach it. Medicare.gov publishes the current amounts.
How do Medicare Advantage appeals work?
About 1,346,766 North Carolinians had Medicare Advantage in July 2026, so for most people in the state the plan makes the first decision. The steps have different names:
- Organization determination. The plan decides whether it will cover a service or pay a claim, including prior authorization. If waiting could seriously harm your health, you or your doctor can ask for a fast decision.
- Reconsideration (level 1). If the plan says no, you, your representative or your doctor can appeal within 65 days of the date on the denial notice. The plan decides within 30 days for a service you haven't received, 60 days for a payment, 7 days for a Part B drug, or 72 hours for a fast appeal; it can take up to 14 more days in some cases and must tell you in writing.
- Independent Review Entity (level 2). If the plan keeps its denial, it must send your case automatically to an independent reviewer. You don't have to file anything.
- Levels 3 to 5. Same as Original Medicare: a hearing, the Medicare Appeals Council, then federal court, with the same yearly minimum amounts.
State Health Plan retirees in the Base or Enhanced Plan have group Medicare Advantage coverage, so these steps apply to them too; the Plan's member materials say where to send an appeal. See State Health Plan retirees and Medicare.
How do Part D drug appeals work?
- Coverage determination. Ask your plan to cover a drug, including an exception (to cover a drug not on its list, waive a step-therapy or quantity rule, or lower your cost-sharing tier). Your prescriber's statement explaining the medical reason helps. If waiting could seriously harm your health, ask for a fast decision.
- Redetermination (level 1). If the plan says no, ask for a redetermination within 65 days of the date on the denial notice. The plan decides within 7 days (14 days for a payment request), or 72 hours for a fast appeal.
- Independent Review Entity (level 2). Unlike Medicare Advantage medical appeals, you must ask for this review yourself, within 60 days of the plan's decision.
- Levels 3 to 5. A hearing, the Medicare Appeals Council and federal court, with yearly minimum amounts for levels 3 and 5.
Tip: If drug costs are the problem rather than a denial, Part D's yearly out-of-pocket cap is $2,400 in 2027, and you may qualify for Extra Help or a Medicare Savings Program. See Extra Help in North Carolina and our drug cost cap calculator.
What if my hospital stay or care is ending too soon?
When covered care is ending, a separate, faster process applies. In North Carolina, these appeals go to Acentra Health, the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO), at 1-888-317-0751 (TTY 711). The number is also on your notice. This works the same way with Original Medicare and with Medicare Advantage.
Leaving the hospital
You should get An Important Message from Medicare about Your Rights within 2 days of admission and again before discharge. If you think you're being discharged too soon, follow its directions no later than your planned discharge day. Acentra Health decides within one day of getting the information it needs. If you ask on time, you can stay while it decides without paying for the extra days, other than usual deductibles or coinsurance.
Skilled nursing, home health, hospice
You should get a Notice of Medicare Non-Coverage at least 2 days before covered services end at a skilled nursing facility, from a home health agency or hospice, or at a comprehensive outpatient rehabilitation facility. To appeal, call Acentra Health by noon of the day before the date on the notice.
Acentra Health also reviews complaints about the quality of care you got from a doctor, hospital or other provider under Medicare, and offers Immediate Advocacy, an informal way to resolve some problems quickly while you're still getting care. Step-by-step help: how do I appeal a hospital discharge in North Carolina?
What if a nursing home says my parent must leave?
Acentra Health points out that its review of a skilled nursing stay decides only whether Medicare keeps paying, not whether someone may stay in the facility. A notice telling a resident to transfer or leave is a different decision. In North Carolina, residents can appeal a transfer or discharge notice from a nursing home (10A NCAC 22H .0200) or an adult care home (G.S. 131D-4.8) to the NC Medicaid Hearing Office, at 919-814-0090, using the hearing request form on NC Medicaid's appeals page. Act quickly, because deadlines apply. The regional long-term care ombudsman can explain the notice; see North Carolina Medicare contacts.
If you also have NC Medicaid
People with both Medicare and full NC Medicaid are served through NC Medicaid Direct, and every dual eligible special needs plan (D-SNP) in North Carolina for 2027 is a coordination-only plan, so Medicare and Medicaid keep separate appeals. Appeal a Medicare or D-SNP decision with the steps above. For a Medicaid decision, such as a denied application, a reduced benefit or a CAP/DA decision, your notice from the county DSS or NC Medicaid explains your hearing rights and the deadline; call the NC Medicaid Contact Center, 1-888-245-0179, with questions. See NC Medicaid and Medicare and D-SNPs in North Carolina.
How do I appeal IRMAA (higher premiums based on income)?
Social Security, not Medicare, decides whether you pay the income-related monthly adjustment amount on Part B and Part D premiums, using your tax return from two years earlier. The brackets are cliffs: one dollar over a limit raises the whole amount. You can ask Social Security for a new decision with Form SSA-44 if your income dropped after a life-changing event, such as retiring from a North Carolina public or private job, marriage, divorce or the death of a spouse; or ask for a reconsideration within 60 days if the tax information was wrong. Estimate your bracket with our IRMAA calculator and see how to appeal IRMAA after retiring.
What about complaints that aren't appeals?
If your problem isn't a coverage or payment decision, such as long waits, trouble reaching customer service or how you were treated, file a grievance with your Medicare Advantage or Part D plan; your plan's Evidence of Coverage explains how and by when. You can also tell Medicare about a problem with a plan at 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048).
The North Carolina Department of Insurance (NCDOI) regulates insurance companies and licenses agents. It can't change a Medicare coverage decision, but it takes complaints about insurers and agents, including Medicare supplement (Medigap) insurers, through its online complaint page. See how to file a complaint about an insurance agent in North Carolina.
When an appeal isn't the answer
If a plan keeps denying a drug or service you need, or a doctor you rely on leaves its network, it may make sense to change plans during an enrollment period you qualify for. Open Enrollment runs through December 7, 2026, and people whose plan is ending have more time; see plans ending in 2027. A licensed insurance agent who works with Benefits Life can explain plans from the companies they work with and when you can switch, at no cost to you; you can request a call from a licensed insurance agent. For the appeal itself, follow the instructions on your notice. Suspicious charges? See Medicare fraud in North Carolina.
Sources
- Medicare.gov — Appeals in Original Medicare
- Medicare.gov — Appeals in Medicare health plans
- Medicare.gov — Appeals in Medicare drug plans
- Medicare.gov — Fast appeals
- CMS — Beneficiary and Family Centered Care QIOs
- Acentra Health BFCC-QIO — How to file an appeal
- Acentra Health BFCC-QIO — Immediate Advocacy
- NC Medicaid — Appeals (Hearing Office: nursing home and adult care home discharge appeals)
- N.C.G.S. 131D-4.8 — Adult care home discharge
- Social Security — Request to lower an IRMAA
- NC Department of Insurance — Assistance or file a complaint
Frequently asked questions
How long do I have to file a Medicare appeal?
For Original Medicare, 120 days from the date you get your Medicare Summary Notice. For a Medicare Advantage or Part D plan denial, 65 days from the date on the plan's notice. Later levels generally must be requested within 60 days, except the second Original Medicare level, which allows 180 days.
Who is the Medicare quality improvement organization for North Carolina?
Acentra Health is the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for North Carolina. Call its helpline at 1-888-317-0751 (TTY 711) for fast appeals of a hospital discharge or other covered care ending, and for complaints about the quality of care.
Can the North Carolina Department of Insurance overturn a Medicare denial?
No. Medicare coverage decisions follow the federal appeals process. NCDOI takes complaints about insurance companies and agents, including Medigap insurers, through its online complaint form, but it can't change a Medicare decision.
What if a nursing home in North Carolina tells my parent to move out?
A notice of transfer or discharge from a nursing home or adult care home is different from a Medicare coverage notice. The resident can appeal it to the NC Medicaid Hearing Office (919-814-0090) using the hearing request form, and the regional long-term care ombudsman can help explain the notice.
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