How long do I have to appeal a denied claim?

There is no single answer, and anyone who gives you one number is giving you a number that is wrong for most of your claims. The window depends on who the payer is and, for commercial plans, on what you signed.

Original Medicare, fee-for-service

Medicare publishes a five-level appeals process with fixed timeframes at each level. In outline:

• Redetermination by the Medicare Administrative Contractor — 120 days from receipt of the initial determination.
• Reconsideration by a Qualified Independent Contractor — 180 days from the redetermination notice.
• Administrative law judge hearing — 60 days, and subject to a minimum amount-in-controversy that is adjusted every year.
• Medicare Appeals Council review — 60 days.
• Judicial review in federal district court — 60 days, with a higher amount-in-controversy threshold.

Two details matter more than the numbers. The clock runs from receipt of the notice, and receipt is presumed a set number of days after the notice date unless you can show otherwise. And the dollar thresholds at the upper levels change annually, so never work from a remembered figure. Confirm the current rules at cms.gov.

Medicare Advantage and Part D

Part C and Part D do not use the fee-for-service timetable above. They run their own reconsideration processes through the plan, and non-contracted providers have a separate route with its own paperwork requirements. Get the deadline from that plan's provider manual, not from a Medicare fee-for-service reference.

Commercial plans

Your participation agreement sets the window first, and state prompt-pay and appeal statutes sit underneath it. The ranges genuinely vary by payer, by product line and by state, which is why we are not printing a number here. Look at the contract and the payer's current provider manual, and if the two disagree, ask the payer which one governs and write down the answer.

Self-funded plans under ERISA

The federal claims regulation for ERISA group health plans requires that claimants get at least 180 days to appeal an adverse benefit determination. As a provider you generally get there through an assignment of benefits or as the patient's authorized representative, and the plan document controls the specifics. Whether a plan is self-funded is not obvious from the ID card, so confirm it.

Medicaid

State by state, and different again for managed care organizations within a state. The state Medicaid provider manual or the MCO manual is the authority.

Three clocks people confuse

Timely filing governs the original submission. The corrected claim window governs resubmitting a claim you got wrong. The appeal window governs disputing a determination the payer got wrong. They are different deadlines with different starting points, and missing one does not automatically mean you have missed another. Picking the wrong one is how a recoverable denial becomes a write-off.

Rules that hold up with any payer

• Date-stamp remittances on receipt. The clock usually starts at the notice date, not your work date.
• Ask the representative for the deadline that applies to this claim, and capture the call reference number that proves they told you.
• File in writing and keep proof of delivery.
• Work one level at a time. Skipping a level usually restarts you at the bottom, later.