> ## Documentation Index
> Fetch the complete documentation index at: https://docs.rcintell.com/llms.txt
> Use this file to discover all available pages before exploring further.
# Appeal processes
> Medicare and commercial appeal timelines, levels, and how RCI provides payer-specific deadlines
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:
```bash theme={null}
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"}'
```
```json theme={null}
{
"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:
```bash theme={null}
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.
Understand CARC and RARC codes before filing an appeal.
Learn how different payer types affect billing and appeals.