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 3,051,948 Floridians had Medicare Advantage in July 2026, more than half of everyone with Medicare in the state, so for most Floridians 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.
Florida state retirees in the State Group Insurance program's Medicare Advantage options have group Medicare Advantage coverage, so these steps apply to them too; the plan's member materials say where to send an appeal. See Florida state 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 Florida 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 Florida, 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: how to appeal a hospital discharge in Florida.
What if a Florida nursing home says my parent must leave?
A Medicare non-coverage notice decides only whether Medicare keeps paying. A nursing home's notice telling a resident to transfer or leave is a different decision, with its own Florida rights under Fla. Stat. 400.0255:
- The nursing home generally must give written notice at least 30 days before a transfer or discharge, with shorter notice allowed only in limited situations.
- The resident, or their representative, can ask for a fair hearing with the Department of Children and Families' Office of Appeal Hearings within 90 days of receiving the notice.
- If the hearing is requested within 10 days, the resident generally can stay in the facility until the hearing decision, except in an emergency discharge.
- The resident can ask the Long-Term Care Ombudsman Program (1-888-831-0404) to review the notice; the ombudsman can also help file the appeal.
If you also have Florida Medicaid
Most people with full Florida Medicaid get their Medicaid services through a Statewide Medicaid Managed Care (SMMC) plan, which has its own appeals. Appeal a Medicare or Medicare Advantage decision with the steps above. For a decision by your Medicaid plan, such as a denied or reduced Medicaid service, you must first file a plan appeal by the deadline on the plan's notice. If the plan doesn't decide fully in your favor, you can ask for a Medicaid fair hearing with AHCA's Office of Fair Hearings; AHCA must receive the request within 120 days of the date the plan's appeal decision notice is sent (Rule 59G-1.100, F.A.C.). For a decision about Medicaid eligibility, such as a denied ACCESS Florida application, follow the hearing instructions on your DCF notice. Questions about Medicaid plans and services go to the AHCA Medicaid Helpline, 1-877-254-1055. If you're in a dual eligible special needs plan (D-SNP), its notices explain which steps apply. See Florida Medicaid and Medicare and D-SNPs in Florida.
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 work, 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 Florida Department of Financial Services (DFS) takes complaints about insurance companies, agents and agencies, including Medicare supplement (Medigap) insurers, through its Consumer Helpline, 1-877-693-5236, and its online Consumer Assistance Portal. It can't change a Medicare coverage decision. See how to file a complaint against a Medicare agent in Florida.
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 Florida.
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
- Acentra Health BFCC-QIO — How to file an appeal
- Acentra Health BFCC-QIO — Immediate Advocacy
- Fla. Stat. 400.0255 — Nursing home resident transfer or discharge; hearings
- Florida Department of Elder Affairs — Long-Term Care Ombudsman Program
- Rule 59G-1.100, F.A.C. — Medicaid fair hearings
- AHCA — Florida Medicaid complaints and Medicaid Helpline
- Florida Department of Financial Services — Need our help?
- Social Security — Request to lower an IRMAA
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 Florida?
Acentra Health is the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) for Florida. Call its helpline at 1-888-317-0751 (TTY 711) for a fast appeal when a hospital discharge or other covered care is ending, and for complaints about the quality of care.
Can the Florida Department of Financial Services overturn a Medicare denial?
No. DFS says the Centers for Medicare and Medicaid Services has jurisdiction over Medicare, so Medicare Advantage and Part D decisions follow the federal appeals process. DFS takes complaints about insurance companies and agents, including Medigap insurers, at 1-877-693-5236.
What if a Florida nursing home tells my parent to leave?
Under Fla. Stat. 400.0255, the resident can ask for a fair hearing with the Department of Children and Families' Office of Appeal Hearings within 90 days of the notice. Asking within 10 days generally lets the resident stay until the hearing decision. The Long-Term Care Ombudsman Program, 1-888-831-0404, can review the notice.
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