Glossary
Claim Appeal
The formal process for asking Medicare or TFL to reconsider a denied or underpaid claim.
Also known as: appeal, redetermination
Quick answer
Medicare appeals follow five levels, starting with a 'redetermination' by your MAC. TFL appeals are filed with WPS within 90 days of the EOB date. Both processes are free.
Why it matters
Many initial denials are reversed on appeal — especially for medical-necessity disputes. Not appealing leaves money on the table.
When you'll encounter it
Whenever an MSN or EOB shows 'denied' or pays substantially less than expected.
Impact on Medicare
Levels: redetermination → reconsideration (QIC) → Administrative Law Judge → Medicare Appeals Council → federal court.
Impact on TRICARE For Life
TFL allows appeals on factual issues (e.g., medical necessity), filed in writing to WPS within 90 days.
Common misconceptions
- "Appeals require a lawyer." — They don't, though one can help at higher levels.
Common mistakes to avoid
- Missing the 90- to 120-day filing deadline.
- Filing without supporting medical records.
Real-world scenario: Medicare denies an MRI as 'not medically necessary.'
Patient requests a redetermination with a supporting letter from their physician; denial is reversed within 60 days.
What should I do?
- 1Note the filing deadline on the MSN/EOB the moment it arrives.
- 2Request supporting documentation from your provider in writing.
- 3Use the official appeal form (CMS-20027 for Medicare; WPS appeal form for TFL).
- 4Keep copies of everything you send.
Questions people commonly ask
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- AppealA formal request to review and reverse a denial, partial payment, or coverage decision by Medicare, a Medicare plan, TRICARE/TFL, VA, or a drug plan.
- Denial NoticeA written notice from Medicare, an MA plan, Part D plan, TRICARE/WPS, or VA explaining what was denied, why, and how to appeal.
- Medical Necessity AppealAn appeal arguing that a denied service, drug, or device is clinically necessary based on the treating provider's documentation.
- Quality of Care ComplaintA complaint filed with the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) about the quality of medical care you received.
- WPS Claim ReconsiderationThe first-level review of a TRICARE For Life claim decision, filed with Wisconsin Physicians Service (WPS), the TFL contractor.
- Appointment of RepresentativeA signed form (CMS-1696) that authorizes another person — family member, attorney, or advocate — to file or pursue a Medicare appeal on your behalf.
- Balance BillingThe practice of a provider billing you for the difference between their charge and what insurance approved.
- Medicare denied a service. Can I appeal?Yes. The first level for Original Medicare is a Redetermination filed with the Medicare Administrative Contractor (MAC) within 120 days of the denial notice (MSN).
- TFL denied a claim. How do I appeal?WPS handles TFL appeals. File a written reconsideration with WPS within 90 days of the denial. Include the Medicare EOB, the WPS denial, and any supporting medical records.
- What do I do if my Medicare claim is denied?Read the MSN denial reason, gather supporting records, and file a Redetermination with the Medicare Administrative Contractor within 120 days.
- Do I appeal to Medicare or to TFL?Appeal to whichever payer issued the denial. If Medicare denied, appeal Medicare. If WPS denied TFL's share, appeal to WPS.
- Can I get a faster appeal for urgent care?Yes. Both Medicare Advantage and Original Medicare allow expedited appeals when delay could jeopardize your health. Decisions come in 72 hours.
Related glossary terms
Related Official Resources
Continue learning straight from the source. Every link below goes to an official government or DoD resource.
Last reviewed January 2026 against the 2026 Medicare & You and TRICARE For Life handbooks.