Start with the notice
Every denial comes in writing and says how to appeal and by when. Original Medicare denials appear on the Medicare Summary Notice, mailed every four months if you had services and available sooner in your Medicare.gov account. Medicare Advantage and Part D plans send their own written notice. In July 2026, 1,346,766 of North Carolina's 2,328,318 people with Medicare were in Medicare Advantage, so for most North Carolinians the first appeal goes to the plan.
How to file the first appeal
- Read why it was denied. A missing prior authorization, a coding error or a "not medically necessary" finding each needs a different answer.
- Get your doctor's support. Ask for a letter or records explaining why you need the service or drug.
- File by the deadline. Original Medicare: a redetermination request within 120 days, sent to the contractor named on the notice. Medicare Advantage: a reconsideration within 65 days. Part D: a redetermination within 65 days.
- Keep copies. Note who you spoke with and when.
- Read the decision. If you lose, the letter tells you how to go to the next level.
The five levels
| Level | Original Medicare | Medicare Advantage | Part D |
|---|---|---|---|
| 1 | Redetermination by the claims contractor | Reconsideration by the plan | Redetermination by the plan |
| 2 | Qualified Independent Contractor (within 180 days) | Independent Review Entity (sent automatically) | Independent Review Entity (you ask, within 60 days) |
| 3 to 5 | Office of Medicare Hearings and Appeals, the Medicare Appeals Council, then federal court; levels 3 and 5 need a minimum amount in dispute that Medicare sets each year | ||
North Carolina points
- Dual eligibles: North Carolina's 2027 D-SNPs are all coordination-only, so Medicare and NC Medicaid decisions are appealed separately. A Medicaid notice from your county DSS or NC Medicaid explains its own hearing rights.
- State Health Plan retirees in the Base or Enhanced Plan have group Medicare Advantage coverage, so the Medicare Advantage steps apply.
- Help: call 1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048) with questions about the process.
Related questions
How do I appeal a hospital discharge in North Carolina?
Fast appeals with Acentra Health.
How can I help a parent with Medicare?
Filing for a parent.
Medicare phone numbers in North Carolina
Official numbers.
More in Medicare appeals in North Carolina.
Sources
- Medicare.gov — Appeals in Original Medicare
- Medicare.gov — Appeals in Medicare health plans
- Medicare.gov — Appeals in Medicare drug plans
- CMS — Form CMS-1696, Appointment of Representative
- Acentra Health BFCC-QIO — How to file an appeal
More questions in this guide
- How can I help a parent with Medicare in North Carolina?
- How do I appeal a hospital discharge in North Carolina if I'm not ready to go home?
- How do I file a complaint about an insurance agent in North Carolina?
- How do I find a licensed Medicare agent in North Carolina?
- How do I find my area agency on aging in North Carolina?
- How do I report Medicare fraud in North Carolina?
- Medicare phone numbers in North Carolina
Part of the guide: North Carolina Medicare contacts · All questions
Frequently asked questions
Can my doctor appeal for me?
Yes. For a Medicare Advantage service denial or a Part D drug denial, your doctor or prescriber can request the appeal for you. For anyone else, such as a family member, name them on Medicare's Appointment of Representative form (CMS-1696).
What if waiting could harm my health?
Ask for a fast (expedited) decision. A Medicare Advantage or Part D plan must then decide within 72 hours. If your doctor says waiting could seriously harm your health, the plan must speed it up.
Can the North Carolina Department of Insurance help with a Medicare denial?
Not with the decision itself: Medicare appeals follow federal rules. NCDOI takes complaints about insurance companies and agents, including Medigap insurers, through its online complaint form.
Who do I call for a hospital discharge?
That's a different, faster appeal. Call Acentra Health, North Carolina's Medicare quality improvement organization, at 1-888-317-0751 (TTY 711), no later than your planned discharge day.
Medicare in your North Carolina county
Plans, local agents and help, county by county: Wake · Mecklenburg · Guilford · Forsyth · Durham · Cumberland · Buncombe · Union · Johnston · Cabarrus · New Hanover · Gaston · Onslow · Iredell · Alamance · Pitt · Davidson · Brunswick · Catawba · Rowan · All 100 counties →
