Appeal processes

When a claim is denied, providers can challenge the decision through a formal appeal process. Each payer type has its own appeal structure with specific deadlines. Missing a deadline means losing the right to appeal at that level — and potentially losing the revenue permanently.

Medicare appeals (5 levels)

Medicare uses a structured 5-level appeal process. Each level must be exhausted before advancing to the next.

Level	Name	Filed With	Deadline	Decision Timeline
1	Redetermination	MAC (Medicare Administrative Contractor)	120 days from initial determination	60 days
2	QIC Reconsideration	Qualified Independent Contractor	180 days from Level 1 decision	60 days
3	ALJ / OMHA Hearing	Office of Medicare Hearings and Appeals	60 days from Level 2 decision	90 days
4	Medicare Appeals Council	Departmental Appeals Board	60 days from Level 3 decision	90 days
5	Federal District Court	US District Court	60 days from Level 4 decision	Varies

Level 3 threshold: ALJ hearings require a minimum amount in controversy. For 2026, the threshold is $190. Claims below this amount cannot proceed past Level 2.

What to include in a Medicare appeal

Level 1 (Redetermination): Letter explaining why the denial is incorrect, supporting medical records, any relevant LCD/NCD references.
Level 2 (QIC): All Level 1 documentation plus additional clinical evidence, peer-reviewed literature, or expert opinions.
Level 3 (ALJ): Formal hearing request. May include expert testimony. Often the most effective level for overturning complex denials.

Medicaid appeals

Medicaid appeal processes vary by state. Most states provide:

Step	Typical Deadline	Notes
Reconsideration	30-60 days from denial	Informal review by the state agency
Fair hearing	90-120 days from denial	Administrative hearing with a state officer
Judicial review	Varies	State court review of the fair hearing decision

Medicaid timely filing and appeal deadlines differ dramatically by state. Always verify your state’s rules through RCI’s L4 payer layer before filing.

Commercial payer appeals

Commercial payers follow a two-stage process under the ACA (Affordable Care Act):

Stage	Name	Deadline	Decision Timeline
1	Internal appeal	180 days from denial (standard)	30 days (pre-service), 60 days (post-service)
2	External review	4 months from exhausting internal appeal	45 days

Expedited appeals

For urgent situations (active treatment, imminent harm), payers must provide expedited review:

Internal expedited: Decision within 72 hours
External expedited: Decision within 72 hours

Workers’ compensation appeals

Workers’ comp appeals are governed by state workers’ compensation boards:

Step	Typical Deadline	Notes
Reconsideration	30 days	Review by the claims adjuster or employer
Formal hearing	1-2 years	Hearing before a workers’ comp judge
Appeals board	Varies	State-level appellate review

How RCI provides appeal deadlines

RCI’s L4 payer layer returns appeal deadlines and levels for any payer. When you resolve knowledge with a payer, the response includes:

curl -X POST https://api-dev.rcintell.com/v1/knowledge/resolve \
  -H "X-API-Key: kp_test_..." \
  -H "Content-Type: application/json" \
  -d '{"ccn": "170001", "payer": "Medicare Part B"}'

{
  "l4_payer": {
    "payer_name": "Medicare Part B",
    "timely_filing": "12 months",
    "appeal_levels": [
      { "level": 1, "name": "Redetermination", "deadline_days": 120, "filed_with": "MAC" },
      { "level": 2, "name": "QIC Reconsideration", "deadline_days": 180, "filed_with": "QIC" },
      { "level": 3, "name": "ALJ Hearing", "deadline_days": 60, "filed_with": "OMHA" },
      { "level": 4, "name": "Medicare Appeals Council", "deadline_days": 60, "filed_with": "DAB" },
      { "level": 5, "name": "Federal District Court", "deadline_days": 60, "filed_with": "US District Court" }
    ],
    "appeal_deadline": "120 days from initial determination"
  }
}

The denial resolution agent uses this data automatically when you include a ccn in your request:

curl -X POST https://api-dev.rcintell.com/v1/agents/denial-resolution \
  -H "X-API-Key: kp_test_..." \
  -H "Content-Type: application/json" \
  -d '{
    "query": "Claim denied CARC 50 — medical necessity not met",
    "carc": "50",
    "ccn": "170001"
  }'

The agent will recommend the appropriate appeal level, calculate the deadline based on the payer’s rules, and suggest the documentation needed to overturn the denial.

Denial codes

Understand CARC and RARC codes before filing an appeal.

Payer types

Learn how different payer types affect billing and appeals.

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Appeal processes

Medicare appeals (5 levels)

What to include in a Medicare appeal

Medicaid appeals

Commercial payer appeals

Expedited appeals

Workers’ compensation appeals

How RCI provides appeal deadlines

Denial codes

Payer types

​Medicare appeals (5 levels)

​What to include in a Medicare appeal

​Medicaid appeals

​Commercial payer appeals

​Expedited appeals

​Workers’ compensation appeals

​How RCI provides appeal deadlines

Denial codes

Payer types

Medicare appeals (5 levels)

What to include in a Medicare appeal

Medicaid appeals

Commercial payer appeals

Expedited appeals

Workers’ compensation appeals

How RCI provides appeal deadlines