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Office of Medicare Hearings and Appeals (OMHA)

Appeals Process by Medicare Type

There are four distinct health insurance programs within the Medicare program and each has its own appeals process. These health insurance programs are referred to as "parts." It is important that you know under what part of the Medicare program you received medical services or items in order to appeal a decision regarding those benefits.

Text only version of table. Skip to Description of Medicare Parts.

Types of Medicare Programs:
Level 1	Medicare Contractor*	Medicare Advantage Plan	Prescription Drug Plan

Level 2	QIC	Independent Review Entity

Level 3	Office of Medicare Hearings and Appeals

Level 4	Medicare Appeals Council (MAC)

Level 5	Federal Court
* In each part of the Medicare program, the Medicare contractor administering the program (usually an insurance company) makes a decision about your Medicare benefits. In most cases, the decision is whether or not a medical service or item is covered and how much the Medicare program will pay for the service or item. There are different names for these decisions depending on the part of the Medicare program covering the benefits.
Text only version of table.

Description of Parts of Medicare

Medicare Parts

Description

Parts A&B
Original Medicare:

Parts A & B or “Original Medicare” includes Hospital Insurance (Part A) and Supplementary Medical Insurance (Part B).

Hospital insurance (Part A) helps pay for inpatient care in a hospital or skilled nursing facility (following a hospital stay), some home health care and hospice care.

Medical insurance (Part B) helps pay for doctors’ services and many other medical services and supplies that are not covered by hospital insurance.

Part C:
Medicare Advantage Plan
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Part C is the Medicare Advantage Plan program.

Under the Medicare Advantage program (Part C), Medicare Advantage plans are available in many areas. Beneficiaries with Medicare Parts A and B can choose to receive all of their health care services through one of these Medicare Advantage plans under Part C.

Part D:
Medicare Prescription Drug Plan

Part D is the Medicare Prescription Drug program

Prescription drug coverage (Part D) helps pay for certain medications doctors prescribe for treatment. Beneficiaries obtain prescription drugs through Medicare Prescription Drug Plans.

Please note that the Office of Medicare Hearings and Appeals is responsible only for the Level 3 claims appeals and certain Medicare entitlements and Part B Premium appeals. OMHA is not responsible for levels 1, 2, 4, and 5 of the appeals process. OMHA provides additional information on other levels of appeals to help you understand the appeals process in a broad context.