Who Can Appeal Denied Medicare Claims: Filers and Deadlines

Anyone with a direct stake in a denied Medicare claim can appeal it: the beneficiary whose care was at issue, a representative the beneficiary appoints in writing, a person who already holds legal authority to act for the beneficiary (a guardian, power of attorney holder, or estate representative), and the provider or supplier who furnished the service. Federal regulations name each of these as a party to the initial claim determination, which is what gives them the right to challenge it.¹ Who actually files depends on the beneficiary’s situation and, in some cases, on paperwork signed before the appeal begins.

The Beneficiary

If you are enrolled in Medicare and a claim tied to your care is denied, you are the primary person with standing to appeal. That covers a refusal to cover a service, item, supply, or prescription drug you believe should be covered; a refusal to pay for something you already received; and a dispute about the amount you owe.² You are recognized as a party whenever a claim is filed on your behalf or by your provider,¹ and that status carries through every level of appeal.

You do not need permission from your doctor, an insurance coordinator, or anyone else to start. A Medicare Summary Notice or an Explanation of Benefits showing the denial is enough to begin.

Someone You Appoint to Handle the Appeal

You can designate another person to file and pursue the appeal for you. This is called an appointed representative, and it can be a family member, a friend, a patient advocate, an attorney, or anyone else you trust. To make the appointment official, you and the representative both sign the Appointment of Representative form (CMS-1696) and submit it with the appeal.³ Once the form is on file, the representative becomes the main point of contact and can submit evidence, receive notices, and make requests for you.⁴

Fees Your Representative Can Charge

A representative who wants to charge a fee needs approval from the adjudicator handling the case. The representative files a separate petition (OMHA-118) describing the work performed, and the adjudicator decides whether the fee is reasonable based on complexity, skill, time spent, and outcome. A provider or supplier who furnished the service at issue and is acting as your appointed representative cannot charge you any fee for the representation.⁵

Someone With Legal Authority to Act for You

An authorized representative is different from an appointed one. Their power comes from state law or a court order rather than a CMS form. Examples include a court-appointed guardian, an executor or administrator of an estate, a person holding a durable or non-durable power of attorney, and individuals designated under a state healthcare consent statute.⁵ Because the authority already exists outside Medicare, the CMS-1696 form is not required.

This route matters most when the beneficiary can no longer communicate or make decisions. A guardian or power of attorney holder can pursue or continue a Medicare appeal without a signed appointment from the beneficiary.

When the Beneficiary Has Died

If a beneficiary dies with a pending or potential Medicare appeal, the legal representative of the estate can file or continue it. If there is no formal estate, a person who has taken responsibility for settling the decedent’s affairs may file, but the Medicare Administrative Contractor will require proof — a will, probate court letters, or other documentation acceptable under state law. The contractor typically allows at least 14 calendar days to submit that documentation before dismissing the request.⁶

The estate or surviving family member must still have a financial interest in the outcome. If nothing is owed and nothing would be recovered, the contractor may dismiss the appeal for lack of standing.

Providers and Suppliers

Doctors, hospitals, and medical equipment suppliers can appeal denied claims in their own right. A provider who files a claim for services furnished to a beneficiary, and a supplier who accepted assignment on a claim, are both recognized as parties to the initial determination and have independent appeal rights.¹ Their interest is direct: they delivered a service and Medicare will not pay for it.

Transferring Your Appeal Rights to a Provider

Some providers, particularly non-participating ones who have not signed a Medicare participation agreement, do not automatically qualify as parties. In that situation, you can transfer your appeal rights to them using the Transfer of Appeal Rights form (CMS-20031), which requires both your signature and the provider’s.⁷ No other written agreement will substitute; CMS requires this specific form.⁸

The trade-off is real. Once you transfer your appeal rights, you lose the ability to appeal that claim yourself. In exchange, the provider cannot bill you for the disputed service, aside from your normal deductible and coinsurance, even if Medicare ultimately denies the claim.⁷ That protection ends if you cancel the transfer in writing.

Who Files in Medicare Advantage and Part D

If you are in a Medicare Advantage plan or a Part D prescription drug plan, the same categories of people can appeal, but the first request goes to the private plan rather than a government contractor.

For Medicare Advantage, the beneficiary or a representative requests reconsideration from the plan itself within 60 calendar days of receipt of the plan’s written decision.⁹

Part D adds one person to the list. If a drug plan denies coverage, the beneficiary, the representative, or the prescribing doctor can request a redetermination from the plan within 60 calendar days of receipt.¹⁰ The prescriber’s independent standing at the plan level is a Part D feature; it does not exist in the same form on the Original Medicare side.

Deadlines Apply to Everyone

Whoever files the appeal is bound by the same deadlines. The first level in Original Medicare — a redetermination request to the Medicare Administrative Contractor — must be filed within 120 calendar days from receipt of the initial determination, and receipt is presumed to be five calendar days after the date on the notice.¹¹ Later levels have their own clocks.

A late filing is not always fatal. At every level, the person appealing can ask for a time extension by submitting a written explanation of why the deadline was missed. Reviewers consider the specific circumstances, whether Medicare’s own actions misled the appellant, and whether physical, mental, educational, or language barriers played a role.¹¹ Serious illness, a death in the immediate family, destruction of records, incorrect information from the contractor, or never receiving the denial notice will generally qualify as good cause; not knowing about the right to appeal or simply being busy will not. The same standard applies at reconsideration and carries through the later stages.¹²

1
eCFR. 42 CFR 405.906 – Parties to the Initial Determinations, Redeterminations, Reconsiderations, Hearings, and Reviews
2
Medicare.gov. Filing an Appeal
3
Centers for Medicare & Medicaid Services. Appointment of Representative – Form CMS-1696
4
HHS.gov. Your Right to Representation
5
HHS.gov. OMHA Case Processing Manual Chapter 5 Representatives
6
Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual Chapter 29 – Appeals of Claims Decisions
7
Centers for Medicare & Medicaid Services. CMS 20031 Transfer of Appeal Rights
8
Centers for Medicare & Medicaid Services. Medicare Claims Processing Manual Chapter 29 – Appeals of Claims Decisions – Section: 270.2
9
eCFR. 42 CFR 422.582 – Request for a Standard Reconsideration
10
eCFR. 42 CFR 423.582 – Request for a Standard Redetermination
11
eCFR. 42 CFR 405.942 – Time Frame for Filing a Request for a Redetermination
12
eCFR. 42 CFR 405.962 – Timeframe for Filing a Request for a Reconsideration