The Texas Medicare appeals process runs through five federal levels: a redetermination by Novitas Solutions (the Jurisdiction H contractor that processes Texas Part A and Part B claims), a reconsideration by a Qualified Independent Contractor, a hearing before an Administrative Law Judge, review by the Medicare Appeals Council, and finally a lawsuit in federal district court.1Office of the Law Revision Counsel. 42 USC 1395ff – Determinations; Appeals Each level has its own filing deadline, and the last two require your dispute to meet a minimum dollar amount. Medicare Advantage appeals start with your plan instead of Novitas, then feed into the same federal track.
Where a Texas Medicare Claim Starts
Original Medicare claims from Texas providers are processed by Novitas Solutions, the private Medicare Administrative Contractor assigned to Jurisdiction H.2Centers for Medicare & Medicaid Services. Who Are the MACs: A/B MAC Jurisdiction H (JH) When Novitas pays, partially pays, or denies a claim, that decision is called the “initial determination,” and it sets the clock running on your right to appeal. The notice you receive, usually a Medicare Summary Notice for beneficiaries, explains what was denied and why. Read it carefully: the stated reason shapes the evidence you need at level one.
If you’re in a Medicare Advantage plan (Part C), the initial decision instead comes from your plan and is called an “organization determination.”3Medicare.gov. Appeals in Medicare Health Plans The appeal starts there, not with Novitas.
Level 1: Redetermination by Novitas
The first appeal in Original Medicare is a redetermination filed with Novitas. Someone at Novitas who had no part in the original decision reviews the claim fresh. You have 120 days from the date you receive the initial determination to file, and CMS presumes you received the notice five days after it was mailed.4Centers for Medicare & Medicaid Services. First Level of Appeal: Redetermination by a Medicare Contractor
There is no minimum dollar amount at this level. Send everything that supports the claim: medical records, physician notes, treatment plans, and certificates of medical necessity. Novitas has 60 days to issue a decision.1Office of the Law Revision Counsel. 42 USC 1395ff – Determinations; Appeals
Level 2: Reconsideration by a Qualified Independent Contractor
If the redetermination doesn’t go your way, you can ask a Qualified Independent Contractor (QIC) to reconsider. The QIC is a separate organization with no ties to Novitas. You have 180 days from the date you receive the redetermination decision to file.5Medicare.gov. Appeals in Original Medicare
The QIC reviews the full record built below and can request additional evidence. This is still a paper review, not a hearing. No minimum dollar amount applies.
Level 3: Administrative Law Judge Hearing
The third level is a hearing before an Administrative Law Judge (ALJ) at the Office of Medicare Hearings and Appeals (OMHA). You have 60 days from the QIC’s decision to request the hearing, and the amount in controversy must be at least $200 for 2026.6Federal Register. Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2026
This is the first level where you can give testimony, question witnesses, and argue the case live. If a single denied claim is under the $200 threshold, you can combine multiple claims to meet it. The threshold is adjusted each year for inflation, so confirm the current figure before filing.
Level 4: Medicare Appeals Council Review
If the ALJ rules against you, you can ask the Medicare Appeals Council, part of the Departmental Appeals Board, to review the decision. The filing deadline is 60 days after you receive the ALJ’s decision.5Medicare.gov. Appeals in Original Medicare The Council can also pull an ALJ decision for review on its own, with no request from either side. This is the last administrative level before the dispute enters federal court.
Level 5: Federal District Court
If the Appeals Council denies relief, you can file a civil action in federal district court. You have 60 days from the Appeals Council’s decision to file, and the amount in controversy must reach at least $1,960 for 2026.6Federal Register. Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2026 At this point the case leaves the Medicare administrative system entirely and is decided by a federal judge. Like the ALJ threshold, the $1,960 figure is adjusted each calendar year.
How Medicare Advantage Appeals Differ
If you’re enrolled in a Medicare Advantage plan, the first appeal is a reconsideration handled internally by the plan itself, not by Novitas.3Medicare.gov. Appeals in Medicare Health Plans If the plan upholds its denial, the case moves automatically to an Independent Review Entity (IRE), an outside organization that conducts a fresh review.
From the IRE forward, Medicare Advantage appeals merge with the Original Medicare track: ALJ hearing at OMHA, then the Medicare Appeals Council, then federal district court. The 2026 dollar thresholds are the same: $200 for the ALJ level and $1,960 for judicial review.6Federal Register. Medicare Program; Medicare Appeals; Adjustment to the Amount in Controversy Threshold Amounts for Calendar Year 2026
Expedited Appeals When Health Is at Risk
When waiting for a standard decision could seriously harm your health, you or your doctor can ask your Medicare Advantage plan for an expedited (fast) appeal. If the plan grants the request, it must decide within 72 hours. Expedited appeals matter most for pre-service denials, where a delay in authorization could worsen your condition before any standard timeline runs its course.
Grievance or Appeal: Choose the Right One
A grievance is not an appeal, and filing the wrong one burns time you may not have. A grievance covers complaints about your experience with the plan: long waits, rude staff, customer service problems. It stays inside the plan’s internal review and never reaches federal review.7GovInfo. Medicare HMO Appeal and Grievance Processes: Beneficiary Understanding
An appeal is what you file when the issue is a denied service, a denied payment, or a coverage decision you disagree with. Only appeals carry the right to independent federal review. If your plan refused to cover something, you need an appeal.
Keeping the Deadlines Straight
Every level has a hard filing deadline, and missing one can end the appeal. For Original Medicare, the pattern is 120 days to request a redetermination from Novitas, 180 days to request QIC reconsideration, 60 days to request an ALJ hearing, 60 days to request Appeals Council review, and 60 days to file in federal district court. Each clock starts when you receive the prior decision, and CMS presumes delivery five days after the notice is mailed unless you can show otherwise. Save the envelope, save the notice, and calendar the deadline the day it arrives.