Newsroom · Grand Junction
How Do I Appeal a Denied Medicare Claim in Colorado?
A denial letter is a first answer, not a final one — and the numbers say most people who push back get a different answer.
The bottom line
- Two different clocks. Original Medicare gives you 120 days from the date on your Medicare Summary Notice. A Medicare Advantage or Part D plan gives you only 60 days from the denial letter.
- Ask for a fast decision if you're waiting on care. An expedited appeal is decided in 72 hours instead of 30 days.
- Five levels, but the fight is usually over at Level 1 or 2. If your plan upholds its own denial, it must send the case to an independent reviewer automatically.
- Being discharged too soon is its own appeal. Call the review organization on the notice before you leave the hospital — you stay, and you don't pay for the extra days.
- Appeals work. Nationally, only 11.5% of denied Medicare Advantage prior authorizations were appealed in 2024 — and 80.7% of those appeals were overturned.
The letter usually shows up on a Tuesday, it runs two pages, and somewhere in the middle it says the service is "not medically necessary." I've read a lot of these at kitchen tables in Grand Junction and Fruita, and the reaction is almost always the same — people assume a decision has been made about them, by someone who knows more than they do, and that the matter is closed. It isn't. An initial denial is the first read of a file by someone who has never met you, and Medicare builds in five separate chances to get a different answer. Here is how to use the first one, which is the one that usually works.
Step one: find out which notice you got
Every appeal starts from a piece of paper, and the paper determines both your deadline and where you send it. This is the sorting I do before anything else:
| What you received | Your window | First move |
|---|---|---|
| Medicare Summary Notice (Original Medicare) | 120 days | Arrives every 3 months. Circle the denied line and request a redetermination. |
| Plan denial letter (Medicare Advantage) | 60 days | Ask the plan for a reconsideration. Expedited if a delay would hurt you. |
| Part D coverage determination denial | 60 days | Ask for a redetermination; get your prescriber's supporting statement. |
| An Important Message from Medicare | Before you leave | Hospital discharge. Call the review organization on the notice — same day. |
| Notice of Medicare Non-Coverage | By noon the next day | Skilled nursing, home health or rehab ending. Fast-track appeal. |
| No notice at all, just a bill | Call first | Ask the provider to submit the claim. You cannot appeal a claim never filed. |
Sources: Medicare.gov: Appeals in Original Medicare · Medicare.gov: Appeals in Medicare health plans · Medicare.gov: Fast appeals.
That last row catches more people in Mesa County than you'd think. A bill with no Medicare notice behind it usually means the claim was never submitted, or was submitted with the wrong code. There is nothing to appeal yet — call the provider's billing office first and ask them to file or refile it.
If you have Original Medicare: the 120 days clock
Original Medicare mails you a Medicare Summary Notice every three months, listing what was billed, what Medicare paid, and what it denied. You have 120 days from the date on that notice to file a redetermination request with the Medicare Administrative Contractor named on it, and the contractor then has about 60 days to answer.
You can use the form that comes with the notice, or write a letter. Either way, include four things: your name and Medicare number, the exact service and date being appealed, the reason you believe it should be covered, and the name of anyone you're appointing to act for you. Then attach the piece that actually moves the needle — a letter from the treating physician explaining why the care was medically necessary. In my experience the appeals that fail are not the ones with a weak argument; they're the ones with no clinical documentation attached at all.
If the redetermination comes back denied, you have 180 days to ask a Qualified Independent Contractor for a Level 2 reconsideration — a genuinely separate organization from the one that said no the first time.
If you have Medicare Advantage: 60 days, and the plan has to forward it
Advantage plans deny in two directions: before the fact, by refusing prior authorization for something your doctor wants to do, and after the fact, by refusing to pay a claim. Both are appealed the same way — you ask the plan for a reconsideration within 60 days of the date on the denial notice.
Two features of this process are worth knowing before you need them:
- You can demand speed. If waiting the standard 30 days could seriously harm your health, ask for an expedited appeal and the plan has 72 hours. Your doctor can request it for you, and when a physician says the delay is dangerous, the plan has to treat it as expedited.
- Level 2 is automatic. If the plan reviews its own denial and stands by it, it does not get to close the file. It must send your case to an Independent Review Entity on its own. You don't have to file anything to get there.
Part D drug denials work on a similar clock with an extra first step: you request a coverage determination (72 hours standard, 24 hours expedited), and if that's denied, a redetermination from the plan. Your prescriber's supporting statement is not optional here — it is effectively the whole case.
If prior authorization itself is what tripped you up, we wrote separately about what changed in the pre-approval rules on January 1, 2026.
The five levels, in the order they happen
| Level | Who decides | Deadline to file |
|---|---|---|
| Level 1 — Redetermination | Original Medicare: the Medicare Administrative Contractor. A plan: the plan itself reconsiders. Most wins happen here. | 120 days / 60 days |
| Level 2 — Independent review | A Qualified Independent Contractor, or for plans, an Independent Review Entity your plan must forward the case to automatically. | 180 days / automatic |
| Level 3 — Administrative Law Judge | A hearing at the Office of Medicare Hearings and Appeals. Requires at least $200 in dispute for 2026. | 60 days |
| Level 4 — Medicare Appeals Council | Review of the judge's decision by the Departmental Appeals Board. | 60 days |
| Level 5 — Federal district court | Judicial review, with a much higher dollar threshold that CMS adjusts annually. | 60 days |
Sources: Medicare.gov: Medicare Appeals (official guide, product 11525) · CMS: Second Level of Appeal — Reconsideration by a Qualified Independent Contractor · CMS: Third Level of Appeal — Decision by the Office of Medicare Hearings and Appeals. The $200 amount-in-controversy threshold is the 2026 figure and is adjusted annually.
Most people never see Level 3. That's not a failure of the system — it's what it looks like when the early levels work. The value in knowing the whole ladder exists is that it tells you the plan's second "no" is not the end either.
Got a denial letter you don't understand?
Send it over and I'll tell you which of the five ladders you're on, what your actual deadline is, and what to ask your doctor for. Free, no pressure, and there's nothing to buy — (970) 644-6954 reaches our Grand Junction office.
Ask Brian a question →The fastest appeal in Medicare: "you're being discharged today"
This one is separate from everything above, it runs on hours instead of weeks, and almost nobody uses it.
Within two days of a hospital admission, you must be given a notice titled "An Important Message from Medicare." It's easy to sign and forget in the blur of an admission, but it is the document that carries your discharge-appeal rights. If the hospital says it's time to go and you or your family believe it isn't safe, call the Quality Improvement Organization listed on that notice before you leave. Per Medicare.gov, while that review is pending the hospital cannot discharge you and you are not charged for the additional days. The hospital must then give you a Detailed Notice of Discharge explaining its reasoning, and the reviewer generally calls with a decision within about a day of receiving what it needs.
The same fast-track applies when skilled nursing, rehab or home health is ending: that notice is a Notice of Medicare Non-Coverage, and it has to reach you at least two days before the last covered day. On the Western Slope this matters more than it does in Denver, because a discharge that's two days early can mean a two-hour drive back for a readmission. If rehab coverage is your situation, the day counts themselves are worth reading — we covered those in how many days Medicare pays for rehab.
Do appeals actually work? The numbers say yes
KFF analyzes the prior authorization data Medicare Advantage insurers are required to file with CMS. Here is what the 2024 filings showed nationally:
Source: KFF: Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024 (Jan 28, 2026), analyzing data insurers file with CMS. National aggregates across all plans — not a rating of any plan.
Read those last two together, because that is the whole argument of this article. Roughly nine out of ten denials were simply accepted. Of the one in ten that got challenged, more than four in five came back reversed. A newer KFF review of the transparency metrics insurers must now report, published August 13, 2026, found 12% of standard prior authorization requests denied in 2025 and 67% of denials overturned on appeal. The percentages move depending on what's being measured; the shape of the finding doesn't.
None of that means every denial is wrong, and I'm not going to tell you it is. Some services genuinely aren't covered by Medicare at all, and no appeal fixes that. But "not medically necessary" is a judgment call made from a file, and judgment calls are exactly what a second reviewer with your doctor's letter in hand can change.
Why this lands harder in Mesa County
Denials cluster around chronic disease management and post-hospital care, and here's the local baseline:
Chronic-condition rates among Mesa County adults
Source: CDC PLACES, 2023 — via the Medicare On Main Data Desk. Model-based prevalence among adults, 2023.
Grand Junction is the referral hub for a very large piece of western Colorado and eastern Utah, which means two things for appeals. First, a lot of care here is specialist and post-acute care — the categories where prior authorization shows up most. Second, when someone from Delta, Montrose or Moab is admitted here, the family making the discharge-appeal call is often two hours away and working from a photo of a notice texted from a hospital room. If that's you, the number on the notice still works from anywhere, and so does ours.
What to do, in order
- Write the deadline on the envelope the day it arrives. 120 days for Original Medicare, 60 days for a plan. Everything else is recoverable; a blown deadline mostly isn't.
- Call the provider's billing office before you assume it's a denial. Wrong code, wrong date, claim never filed — these are common and are fixed with a phone call, not an appeal.
- Ask the treating doctor for a letter of medical necessity. Specific: the diagnosis, what was tried, why this service, what happens without it.
- Ask for expedited review if you're still waiting on care. 72 hours instead of 30 days, and your doctor's word that a delay is dangerous carries weight.
- Appoint someone in writing if you want help. A spouse, an adult child, the doctor's office, or your agent can act for you once you put it in writing.
- Keep going after the first no. Level 2 is a different organization — and in a plan, your case goes there automatically.
- Save every page. Notices, letters, dates, names, and what time you called. Appeals are won on paper.
How we know all this: the Medicare On Main Data Desk frames every article with public data — here, Medicare.gov's own pages on appeals in Original Medicare, appeals in Medicare health plans and fast appeals, plus the official Medicare Appeals guide (product 11525); CMS's descriptions of the second and third levels of appeal, including the $200 amount-in-controversy threshold for 2026; CMS's Beneficiary and Family Centered Care Quality Improvement Organization program for hospital-discharge and end-of-care appeals; KFF's analyses of the prior authorization data Medicare Advantage insurers file with CMS (January 2026 and August 2026); and Mesa County health figures from CDC PLACES (2023) — and qualitative guidance for anything that changes year to year. National denial and overturn figures describe all plans in aggregate and are not a rating of any plan. This is education, not advice; confirm your plan, costs, and appeal rights with a licensed agent, your plan, or Medicare.gov. We take no payment from any carrier to feature a plan.
Frequently asked questions
How do I appeal a denied Medicare claim?
Start with the notice, because the notice tells you which door you're walking through. If you have Original Medicare, the denial shows up on your Medicare Summary Notice, and your first step is a redetermination request to the Medicare Administrative Contractor listed on that notice — you have 120 days from the date on it. If you have a Medicare Advantage plan, the denial comes from the plan itself, and you ask the plan for a reconsideration within 60 days. Either way, put it in writing, say plainly what was denied and why you believe it should be covered, and ask your doctor for a short letter of medical necessity. That doctor's letter is the single thing that most often changes the outcome. Keep a copy of everything and send it in a way you can prove — certified mail or the plan's online portal with a confirmation number.
How long do I have to appeal a Medicare denial?
It depends on which Medicare you have, and the two deadlines are different enough that people miss them. Original Medicare gives you 120 days from the date on the Medicare Summary Notice to request a redetermination, and if that is denied, another 180 days to ask a Qualified Independent Contractor for a reconsideration. A Medicare Advantage or Part D plan gives you only 60 days from the date on the denial notice. If you are still getting care and a delay would hurt you, ask for an expedited — "fast" — decision, and the plan has 72 hours instead of 30 days. If you blow a deadline, you can still ask for it to be accepted for good cause, but do not count on that; calendar the date the day the letter arrives.
What are the five levels of Medicare appeals?
Every part of Medicare uses the same five-level ladder. Level 1 is a redetermination — by the Medicare Administrative Contractor in Original Medicare, or a reconsideration by the plan itself in Medicare Advantage and Part D. Level 2 is review by an independent outside entity: a Qualified Independent Contractor for Original Medicare, or an Independent Review Entity for plans, which your plan must forward the case to automatically if it upholds its own denial. Level 3 is a hearing before an Administrative Law Judge at the Office of Medicare Hearings and Appeals, which requires at least $200 in dispute for 2026. Level 4 is the Medicare Appeals Council. Level 5 is federal district court, with a much larger dollar threshold. In practice, the overwhelming majority of appeals that succeed do it at Level 1 or Level 2.
How often are Medicare appeals successful?
More often than people expect, which is exactly why the low appeal rate is such a problem. KFF's analysis of the data Medicare Advantage insurers file with CMS found that of 52.8 million prior authorization determinations in 2024, 4.1 million were denied — and only 11.5% of those denials were appealed. Of the ones that were appealed, 80.7% were overturned in full or in part. Newer figures from the transparency metrics insurers now have to report tell the same story with different numbers: 12% of standard prior authorization requests denied in 2025, and 67% of denials overturned on appeal. These are national aggregates across all plans, not a rating of any one plan. The practical read is simple: a denial letter is a first answer, not a final one.
Can I appeal if the hospital says I have to leave?
Yes, and it is the fastest appeal in Medicare. Within two days of admission the hospital must give you a notice called "An Important Message from Medicare," which explains your right to appeal a discharge you think is too early. If you disagree with the discharge, call the Quality Improvement Organization on that notice before you leave. While the review is pending, the hospital cannot discharge you and you do not pay for the extra days. The hospital then has to hand you a Detailed Notice of Discharge explaining its reasoning, and the review organization generally calls you with a decision within about a day of having what it needs. The same fast-track process applies when skilled nursing, home health or rehab services are ending — that notice is called a Notice of Medicare Non-Coverage and must arrive at least two days before the last covered day.
Who can help me file a Medicare appeal in Grand Junction?
Several people, and none of them should charge you. You can appoint anyone — a spouse, an adult child, your doctor's billing office, or your agent — to act for you in writing. Your doctor's office often has the strongest ammunition, because the clinical record is the argument. 1-800-MEDICARE can walk you through the Original Medicare forms, and Colorado's Division of Insurance takes consumer complaints about insurance company conduct. And you can call our Grand Junction office at (970) 644-6954 — Brian Penner has been doing this for more than 22 years, and reading a denial letter to figure out which of the five ladders you're on takes about ten minutes and costs nothing. We do not charge for it, and there is nothing to buy.
Sources
- Medicare.gov: Appeals in Original Medicare — the 120 days redetermination window and the Medicare Summary Notice.
- Medicare.gov: Appeals in Medicare health plans — the 60 days plan deadline, expedited requests, and automatic forwarding to independent review.
- Medicare.gov: Fast appeals — hospital discharge and end-of-care fast appeals.
- Medicare.gov: Medicare Appeals (official guide, product 11525) — the five levels, appointing a representative, and what to include.
- CMS: Second Level of Appeal — Reconsideration by a Qualified Independent Contractor — the 180 days Level 2 window in Original Medicare.
- CMS: Third Level of Appeal — Decision by the Office of Medicare Hearings and Appeals — the Level 3 hearing and the $200 2026 threshold.
- CMS: Beneficiary and Family Centered Care Quality Improvement Organizations (BFCC-QIOs) — the organizations that review discharge and end-of-care appeals.
- KFF: Medicare Advantage Insurers Made Nearly 53 Million Prior Authorization Determinations in 2024 (Jan 28, 2026) — 2024 determinations, denials, appeal rate and overturn rate.
- KFF: Prior Authorization Metrics Provide New Insights into Insurer Practices, but Gaps Remain (Aug 13, 2026) — 2025 denial and overturn rates from the new insurer transparency metrics.
- Colorado Division of Insurance — consumer help and complaints — where Colorado residents take complaints about insurer conduct.
- CDC PLACES: Local Data for Better Health, County 2023 — Mesa County chronic-condition prevalence (2023).
