A discharge notice starts a clock measured in hours. On that appeal, the burden of proof is not yours.

Part 1

A discharge notice starts a clock measured in hours. On that appeal, the burden of proof is not yours.

There is no single Medicare appeal. There are several, they run on very different clocks, and the one that applies is fixed by two facts about the situation rather than by anything to do with the merits.

The first fact is whether the coverage is Original Medicare or a Medicare Advantage plan. Those are separate machines with separate rules.

The second is whether care is ending now or a bill has already been refused. Care ending now routes into a fast track measured in hours, where an independent reviewer decides within three days. A refused bill routes into an ordinary chain of five levels measured in months.

The single most useful fact in this guide belongs to the fast track. Federal regulations place the burden of proof on the provider to show that ending coverage is the correct decision. The person appealing is not required to prove they still need care; the hospital or agency is required to prove they do not.

These rules are federal and apply the same way in every state, though the independent review organizations that decide fast appeals are assigned by area. State law governs a hospital's other obligations and is not covered here.

This guide is educational information. It is not legal, tax or financial advice, and it does not say whether any particular decision is worth appealing.

Part 2

Which system you are in, and how to tell within a minute

Before anything else, two questions.

The fast routes are the ones with hours rather than months attached, and they are the ones people miss, because the notice announcing them arrives during a hospital stay or on the day someone is being sent home.

Part 3

When home health, nursing or hospice care is being ended

Before ending services, the provider has to deliver written notice on a standard form, and it has to do so no later than two days before the proposed end. Where the services were expected to last fewer than two days, notice comes at admission.

The appeal then runs on a very short clock.

• The request goes to the independent review organization for the state, by no later than noon of the calendar day following receipt of the notice. It may be made in writing or by telephone.
• The organization must notify its decision no later than 72 hours after receiving the request.
• The burden of proof rests with the provider to show that ending coverage is correct, on medical necessity or other coverage policy.
• The provider may not bill for any disputed services until the process, including any reconsideration, has finished.

What a late request costs, and what it does not

Missing noon does not end the appeal. The rules say the organization will accept an untimely request and decide as soon as possible. What is lost is the 72 hour deadline and the financial liability protection. The appeal survives; the shield does not.

If the fast decision goes against the beneficiary, there is a second fast step: an expedited reconsideration, requested by noon of the calendar day following notification of the first decision. A beneficiary may ask that reviewer for up to fourteen extra days if more time would help.

Part 4

When a hospital says the stay is over

Every Medicare beneficiary admitted to hospital must be given a standard written notice of their rights as an inpatient, including discharge appeal rights, at or near admission and no later than two calendar days after admission.

That notice is handed over on day one, when discharge is not in prospect, and it is usually filed and forgotten. It is the document that explains the fast appeal.

The request, and what a timely one buys

Where a hospital, with a physician's concurrence, determines that inpatient care is no longer necessary, the beneficiary may ask the independent review organization for an expedited determination. The request must be made no later than the day of discharge, in writing or by telephone, and the burden of proof rests with the hospital.

A timely request carries a financial protection written into the regulation. The beneficiary is not financially responsible for inpatient hospital services, other than applicable coinsurance and deductible, furnished before noon of the calendar day after the beneficiary or their representative receives notification of the decision, orally or in writing.

The trigger is receipt rather than issue, which matters wherever there is a gap between the reviewer deciding and the patient being told.

Part 5

The five levels when a claim has been refused

Where Original Medicare has refused to pay, the route is a chain, and a party has to file at every rung.

Two details in that table repay attention. Every deadline runs from receipt, not from the date on the letter, and the regulations presume receipt to be five calendar days after the date of the notice unless there is evidence otherwise. And good cause can extend the first deadline where it has already passed.

The threshold at the third level

A hearing before an administrative law judge also requires a minimum amount remaining in dispute. The regulation does not fix a figure. It sets a base of $100, increased by the rise in the medical care component of the consumer price index measured from July 2003 to the July before the year in question, rounded to the nearest $10, with changes published in the Federal Register.

Combining small claims to get over it

Claims can be aggregated to reach that figure, on three conditions. They must already have been through the second level. The request has to be filed within 60 calendar days after receiving all the reconsiderations being appealed. And the substantive test depends on who is aggregating: one person's own claims must involve the delivery of similar or related services, while claims of several different people must involve common issues of law and fact. Part A and Part B claims may be combined.

The fifth level has a threshold of its own and it is a great deal higher. Judicial review requires an amount remaining in controversy of $1,000 or more, indexed by the same formula. A dispute large enough for a hearing is not automatically large enough for a court.

Part 6

An Advantage plan is a different machine, and one step happens on its own

A Medicare Advantage plan runs its own process, and it differs from Original Medicare in ways that mostly favor the enrollee.

• A request for a standard decision on a service may be made orally or in writing. Only a request for payment has to be in writing.
• The plan must decide a standard service request within 14 calendar days, and, beginning on or after January 1, 2026, within 7 calendar days where the service is subject to the prior authorization rules.
• An expedited decision must come within 72 hours, and for a Part B drug within 24 hours, which the regulation says may not be extended. The expedited track has to be asked for, and who asks decides how it is gated: see below.
• A reconsideration must be requested within 60 calendar days of receiving the plan's written decision, and it can be expedited on an oral or written request.

The step nobody has to take

This is the structural difference worth knowing. Where the plan reconsiders and affirms its own denial, in whole or in part, federal regulations require the issues still in dispute to be reviewed and resolved by an independent outside entity that contracts with the government. The plan has to prepare a written explanation and send the case file, within 30 calendar days for a service request and 60 for a payment request.

The enrollee files nothing for that step. In Original Medicare the equivalent move requires a fresh request within 180 days; in an Advantage plan it happens automatically because the plan lost.

Who can compel the fast track

Either an enrollee or a physician may ask for an expedited determination, orally or in writing. What happens next is not the same in the two cases.

• On a request from the enrollee alone, the plan must expedite if it determines that the standard timeframe could seriously jeopardize life, health, or the ability to regain maximum function. The judgment is the plan's.
• On a request made or supported by a physician, the plan must expedite if the physician indicates that it could. The plan's own view of the medical urgency does not enter into it.

Where the plan refuses to expedite, the request converts automatically to the standard timeframe, and the enrollee gets prompt oral notice plus a written letter within three calendar days explaining that and setting out grievance rights.

A hospital discharge from an Advantage plan does not go through the plan. It goes to the same independent review organization, on the same day-of-discharge deadline, with the same burden of proof on the hospital.

Part 7

When the deadline has gone, and the rule about new evidence

Separately from the appeal chain there is a reopening, which the regulations describe as a remedial action to change a binding decision that produced an overpayment or underpayment, even where that decision may have been correct when it was made on the evidence then available.

One category is not discretionary. A contractor must process clerical errors as reopenings rather than as appeals, and the definition of clerical error is broad: mathematical or computational mistakes, inaccurate data entry, and denials of claims as duplicates.

Evidence, and who the restriction actually binds

At the hearing level there is a rule requiring evidence not submitted before the second level decision to be accompanied by a statement explaining why, failing which it will not be considered. It is a serious rule and it is narrower than it first appears.

The regulation says the requirement does not apply to oral testimony given at a hearing, nor to evidence submitted by an unrepresented beneficiary, by the government or its contractors, by a state Medicaid agency, by a plan, or by a beneficiary represented by someone other than a provider or supplier.

So it binds providers and suppliers, and a beneficiary whose representative is their own provider. It does not bind a beneficiary acting for themselves, or one represented by a family member or a lawyer. Anyone may appoint a representative to act for them under a separate provision, and who that representative is turns out to matter here.

Part 8

The one afternoon checklist

The deadlines measured in hours come first. Everything below them can wait until tomorrow.

• On any hospital admission, keep the written notice of inpatient rights given within two days of admission. It is the document that explains the fast appeal.
• If a hospital says the stay is over, request the expedited review by the day of discharge. A telephone call counts.
• If home health, nursing facility, rehabilitation or hospice care is ending, request review by noon of the day after the notice. A telephone call counts here too.
• Say in the request if the notice arrived late or was never properly given. Invalid notice extends coverage on its own, without any medical argument.
• Remember who has to prove what. On both fast routes the provider or hospital carries the burden, not the patient.
• If the first fast decision goes against you, ask for the expedited reconsideration by noon of the following day.
• File late anyway if the deadline has passed. On the fast routes lateness costs the financial protection, not the right to be heard.
• For a refused claim, count 120 days from receipt, and treat receipt as five days after the date on the notice unless you can show otherwise.
• With an Advantage plan, file once and then check whether the plan has forwarded the case. Where it affirms its own denial, the next review is required to happen without you asking.
• Ask any extension in writing to be justified. Advantage extensions require written reasons and carry a right to file an expedited grievance.
• If a denial looks like a duplicate, a keying error or a computation mistake, ask for a reopening rather than an appeal, and do it early enough that the 120 day appeal deadline is still alive if the answer is no.
• If the fast track matters, get the physician to make or support the request. A physician's indication of urgency compels the plan to expedite; an enrollee's own request leaves that judgment with the plan.