Your Rights

The Medicare Appeals Process: A Washington Beneficiary's Guide

If Medicare, your Medicare Advantage plan or your Part D plan denies a service, drug or payment, you have the right to appeal through five levels, each with its own deadline. For hospital discharges and ending skilled nursing, home health or hospice care, Washington's independent reviewer is Acentra Health, the BFCC-QIO for Region 10, at 1-888-305-6759.

By the Benefits Life Editorial Team, licensed insurance agents · Reviewed November 9, 2026

Why appeals matter

Medicare and plan denials happen, and some are reversed on appeal. If you believe a denied service, item or drug was medically necessary and should be covered, an appeal is how you ask for an independent look. A clear letter from your doctor is often the most important piece of evidence.

Original Medicare vs. Medicare Advantage vs. Part D appeals

The appeals process depends on your coverage:

Original Medicare appeals start with the Medicare Administrative Contractor (MAC) that processed the claim, then go to a Qualified Independent Contractor (QIC).
Medicare Advantage appeals start with your plan, then go automatically to an Independent Review Entity if the plan doesn't decide fully in your favor.
Part D drug denials start with a coverage determination by your plan, then a plan appeal, then an Independent Review Entity that you must ask for.

After the second level, all three paths share Levels 3 to 5.

The five levels of Medicare appeals

Level 1: Redetermination (Original Medicare) or plan reconsideration

Original Medicare: file a "redetermination" with the MAC listed on your Medicare Summary Notice (MSN), by the date shown on the MSN (generally 120 days after you receive it). The MAC generally decides within 60 days.

Medicare Advantage: ask your plan for a "reconsideration" within 65 days of the date on its denial notice. The plan must decide within 30 days for a service you haven't received, 60 days for a payment request, 7 days for a Part B drug, or 72 hours for a fast appeal.

Part D: after your plan's coverage determination, ask for a "redetermination" within 65 days. The plan must decide within 7 days for a drug you haven't received, 14 days for a payment request, or 72 hours for a fast appeal.

Level 2: Independent review

Original Medicare: ask a Qualified Independent Contractor for a "reconsideration" within 180 days of the Level 1 decision. The QIC generally decides within 60 days.

Medicare Advantage: if your plan decides against you in whole or in part, it must send your case to an Independent Review Entity automatically. You don't have to do anything.

Part D: you must ask the Independent Review Entity for a reconsideration within 60 days of the plan's decision. It decides within 7 days for a drug you haven't received, 14 days for a payment, or 72 hours for a fast appeal.

Level 3: Administrative Law Judge (ALJ) hearing

If you disagree with the Level 2 decision, you can ask the Office of Medicare Hearings and Appeals for a hearing before an administrative law judge, or a decision on the record, within 60 days. The amount in dispute must meet a minimum that Medicare sets each year; Medicare.gov lists the current amount. Hearings are usually held by phone or video. You can represent yourself or have someone represent you.

Level 4: Medicare Appeals Council

If you disagree with the ALJ decision, you can ask the Medicare Appeals Council, part of the Departmental Appeals Board of the U.S. Department of Health and Human Services, to review it within 60 days. If the ALJ doesn't decide on time, you may be able to move your case to the Council.

Level 5: Federal district court

If you disagree with the Council's decision, you can file in federal district court within 60 days, if the amount in dispute meets a higher yearly minimum (claims can sometimes be combined to meet it). This is the level where people usually need an attorney.

Fast (expedited) plan decisions

If waiting for a standard decision could seriously harm your life, health or ability to regain maximum function, ask your Medicare Advantage or Part D plan for a fast decision. The plan must decide within 72 hours. If your doctor tells the plan that a fast decision is needed, the plan must give one. Fast decisions fit situations like:

A denied prior authorization for an upcoming procedure or test
A denied prescription you need right away

Fast decisions apply to care you haven't received yet, not to payment for care you already got.

Washington's BFCC-QIO: Acentra Health

For fast appeals when a hospital, skilled nursing facility, home health agency, hospice or outpatient rehabilitation facility says your Medicare-covered services are ending, an independent reviewer called a Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) decides. For Washington, that is Acentra Health, the BFCC-QIO for CMS Region 10 (Alaska, Idaho, Oregon and Washington), at 1-888-305-6759. The BFCC-QIO also handles complaints about the quality of care you received from a Medicare provider.

Hospital discharge appeals

If you're a hospital inpatient, the hospital must give you a notice called the Important Message from Medicare about Your Rights. If you think you're being discharged too soon:

Follow the directions on the notice and call Acentra Health, the BFCC-QIO, at the number on the notice.
Ask for the review no later than the day you're scheduled to be discharged, and before you leave the hospital.
The BFCC-QIO decides within one day after it gets the information it needs.
If you met the deadline, you won't be charged for the hospital stay (other than coinsurance or deductibles) while you wait. If the BFCC-QIO agrees services should end, you generally aren't responsible for hospital charges until noon of the day after its decision.

If you've been changed from inpatient to outpatient observation status, you may also have appeal rights; Medicare.gov explains who qualifies.

Skilled nursing, home health and hospice: services ending

If Medicare-covered care from a skilled nursing facility, home health agency, hospice or comprehensive outpatient rehabilitation facility is ending, you should get a Notice of Medicare Non-Coverage at least 2 days before. To ask for a fast appeal, contact the BFCC-QIO by noon of the day before the end date on the notice. If the BFCC-QIO agrees services should end, you won't pay for services before the end date on the notice.

Part D drug appeals

If your Part D plan won't cover a prescription:

Coverage determination or exception: ask the plan to cover the drug. For an exception (for example, a drug not on the formulary), your prescriber must send a statement explaining the medical reason.
Redetermination by the plan, if it says no (within 65 days)
Independent Review Entity reconsideration, which you must request (within 60 days)
ALJ, Medicare Appeals Council and federal court, if the amount in dispute meets the minimums

Many successful Part D appeals come down to your prescriber explaining why the drugs on the plan's formulary aren't right for you. Get your prescriber involved early.

Tips for a strong appeal

Read the denial notice carefully. It explains why and how to appeal, and gives the deadline.
Gather your records. Medical records, test results and anything else that supports your request.
Ask your doctor for a letter. A clear statement of why the care is medically necessary is often the strongest evidence.
Check Medicare's coverage rules. National and local coverage determinations explain when Medicare covers an item or service; you can search them in the Medicare Coverage Database on CMS.gov.
Meet every deadline. If you file late, you'll have to show a good reason.
Keep copies of everything, including the date you sent your appeal.
Ask for a fast decision if waiting could harm your health.

Complaints, and the Washington Insurance Commissioner

An appeal is about a coverage or payment decision. A complaint (grievance) is about other problems, such as long waits or poor service. Medicare Advantage and Part D plans must have a grievance process; you can also file a complaint with Medicare at 1-800-MEDICARE or on Medicare.gov. Complaints about the quality of care go to the BFCC-QIO.

Medicare Advantage and Part D plans are regulated by CMS, so their appeals go through the federal process above. For a Medigap (Medicare Supplement) policy or other conduct by an insurance company or agent, you can file a complaint with the Washington Office of the Insurance Commissioner at insurance.wa.gov.

Help with Medicare appeals in Washington

1-800-MEDICARE (1-800-633-4227, TTY 1-877-486-2048), for help understanding a denial and the appeal steps
Acentra Health, Washington's BFCC-QIO (1-888-305-6759), for fast appeals when services are ending and quality-of-care complaints
Your plan's member services, at the number on your card, for Medicare Advantage and Part D appeals and grievances
A representative you choose: name a family member, friend, attorney or other person with Form CMS-1696 (Appointment of Representative)
A licensed insurance agent with Benefits Life, at (206) SENIORS (206-736-4677), TTY 711, at no cost to you, if you want to look at other Medicare plans for next year, or you can see plans in your ZIP code

Sources

Frequently asked questions

How long do I have to file a Medicare appeal?

For Original Medicare, file a redetermination by the date shown on your Medicare Summary Notice (generally 120 days after you get it). For Medicare Advantage and Part D, you have 65 days from the date on the plan's denial notice. Hospital discharge appeals must be requested no later than the day you're scheduled to leave. If you miss a deadline, you must show a good reason for filing late.

Who handles fast appeals in Washington?

Acentra Health is the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for CMS Region 10, which includes Washington, Alaska, Idaho and Oregon. Its number is 1-888-305-6759. The number is also on the notice your hospital or provider must give you.

What is an expedited (fast) appeal?

If waiting for a standard decision could seriously harm your life, health or ability to regain maximum function, you can ask your Medicare Advantage or Part D plan for a fast decision. The plan must decide within 72 hours. A doctor's support helps: if your doctor says a fast decision is needed, the plan must give one.

Can I appeal a hospital discharge in Washington?

Yes. The hospital must give you a notice called the Important Message from Medicare about Your Rights. Call Acentra Health, the BFCC-QIO, no later than the day you're scheduled to be discharged and before you leave. If you meet that deadline, you won't be charged for the hospital stay (other than coinsurance or deductibles) while you wait for the decision.

Do I need a lawyer for a Medicare appeal?

No. Most people file appeals themselves, with a letter from their doctor. You can name a family member, friend, attorney or other person to act for you using Form CMS-1696. Level 3 (an administrative law judge) and Level 5 (federal court) require a minimum amount in dispute that Medicare sets each year, and an attorney is usually needed in federal court.

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