Medicare Advantage Appeals Process

Dealing with a denial

It’s critical that you read the denial notice carefully. Understand why your claim or service is being denied.

Understand your rights to appeal and how to appeal.

♦ Most importantly, file an appeal promptly. The odds are in your favor that the plan will overturn its decision.

Don’t be afraid to ask your doctor to write a letter supporting your claim.

• Appeals can be filed for reasons related to your benefits and coverage, with problems related to payment being the most common.

Appeals can be for medical services but also for prescription drugs.

• Prior authorization requests have skyrocketed in tandem with growing enrollment.

Recent healthcare data shows that Medicare Advantage insurers process nearly 53 million prior authorization determinations every single year. Out of those, over 3 million requests are initially denied.

• Shockingly, only about 11.5% of those denials are ever appealed by patients or their doctors.

Yet, the data proves it is entirely worth the effort: between 67% and 81% of all filed appeals successfully result in fully or partially overturning the initial denial, forcing the insurer to authorize or pay for the care.

It pays to appeal.

Medicare Advantage plans were given permission in 2018 to start using step-therapy – requiring a cheaper drug first be used – before a more expensive drug is paid.

If you joined a new plan, it may refuse to pay for an expensive prescription drug until you prove to them that you have already tried other drugs. This can usually be handled over the phone. Your plan may take your word but if the drug is very expensive they will likely call your doctor and confirm.

Appeals Process

• An appeal may be filed by you, someone else acting on your behalf or the provider.

The Medicare Advantage appeals process includes four levels of review by several entities. At each level of review, a denied claim may be overturned, partially overturned, or upheld.

The Center for Medicare and Medicaid Services (CMS) refers to the insurance company and the Medicare Advantage plans they promote as Medicare Advantage Organizations (MAOs). We will refer to them simply as the Plan.

If the denial is overturned, then the Plan must authorize or pay for the service. If the denial is NOT fully overturned the beneficiary or provider may appeal the decision to the next higher level of review.

♦ If any party is dissatisfied with the appeal decisions after completing all four levels of appeal, they may request a review in Federal court.

First-level appeals

The Plan and Quality Improvement Organization

For most first-level appeals, the Plan’s administrator (insurance company) itself must reconsider its decision. (75% of denials are overturned at this stage)

The Plan must review the evidence that led to the original decision and any additional evidence the beneficiary or provider may submit as part of an appeal.

• You must follow your Plan’s procedure for submitting an appeal. Many Plans have been fined by CMS for not providing clear or accurate information needed to submit an appeal. Do not be deterred and do not give-up.

Be prepared to submit a written explanation of why you don’t agree with the initial determination to deny payment or services. Do not be afraid to enlist your doctor’s help. Keep copies of everything.

Once the plan receives your request, it must make its decision and notify you of its decision as quickly as your health requires, but no later than 72 hours for expedited requests, 30 calendar days for standard requests, or 60 calendar days for payment requests.

If the decision is unfavorable to you, in whole or in part, the plan must submit the case file and its decision for automatic review by an Independent Review Entity (IRE).

♦ Plans maintain separate processes to review and resolve appeals from in-network and out-of-network providers.

Appeals from in-network providers generally are considered contractual disputes that are handled by the Plan directly and cannot be appealed to the higher levels of administrative review.

Appeals from out-of-network providers who formally waive their right to bill a beneficiary (you) for the service under appeal may go through the same appeal process. If the Plan upholds its denial for appeals, it must forward the appeal to the next level called an Independent Review Entity for review.

• If the appeal pertains to discharge from a hospital or the discontinuation of certain types of service a Family Centered Care Quality Improvement Organizations will be the first-level review for the appeal. (26% of denials are overturned)

Be prepared to submit a written explanation of why you don’t agree with the initial determination. Be sure to include the dates and specific items or services you are asking to be reconsidered. Do not be afraid to enlist your doctor’s help in making your case.

• Quality Improvement Organizations work under the direction of CMS and are staffed by doctors and other healthcare professionals trained to review medical care and help beneficiaries with complaints about the quality of care.

If the Quality Improvement Organization upholds the Plan’s decision to discharge the beneficiary or to discontinue services, beneficiaries may request that the Quality Improvement Organization reconsider its decision.

If the Quality Improvement Organization upholds its decision again, the beneficiary may appeal to an administrative law judge which would be the third level of this type of appeal.

Second-level appeals

Independent Review Entity

The Independent Review Entity reviews appealed denials that Plans uphold to determine whether the Plan made the correct decision. (10% of denials are overturned)

♦ In most cases, the appeal will be forwarded automatically to C2C Innovative Solutions, a CMS contractor. You must be sure to read all communications you receive to be sure that this was done or not. If not, you can ask them to do so or you may submit the appeal yourself.

•You have 180 days from the date of receipt of the decision from your first-level appeal, to file your request for an Independent review.

You should prepare a written statement explaining why you disagree with the decision to deny your claim. Make sure to state your argument as clearly and in as much detail as possible. Ask your doctor prepared a statement to support your argument.

• A decision on your appeal will usually be issue within 60 days.

The Independent Review Entity is a CMS contractor that employs physicians and other consultants to review the denials and determine whether Plan complied with relevant Medicare requirements.

If the Independent Review Entity upholds or partially overturns the Plan’s denial, beneficiaries and providers may choose to appeal to the next level.

Third-level appeals

Administrative Law Judge

If your second-level appeal is denied, you can request a hearing before an Administrative Law Judge (ALJ) through the Office of Medicare Hearings and Appeals (OMHA).

• The 2026 Dollar Threshold: To qualify for an ALJ hearing, the financial value of your disputed care must meet the current 2026 minimum "Amount in Controversy" threshold of $200.

• The State of the Backlog: Following years of historic case gluts, a federal court order successfully forced the Department of Health and Human Services (HHS) to clear its massive backlog of legacy appeals. Today, OMHA operates on a vastly accelerated timeline.

• What to Expect Now: By law, OMHA is required to issue a decision, dismissal, or remand within 90 calendar days of receiving your hearing request.

If the backlog causes them to miss this deadline, you have the right to escalate your case directly to the next level of review (the Medicare Appeals Council).

• Format: Hearings are highly accessible to beneficiaries and are primarily conducted via telephone or video conference, meaning you do not need to travel.

If the beneficiary, provider, or Plan is dissatisfied with the decision of the administrative law judge, they may choose to appeal to the next level.

Fourth-level appeals

Medicare Appeals Council

The Medicare Appeals Council, within the Departmental Appeals Board, reviews beneficiary, provider, and Plan appeals of decisions by an administrative law judge.

♦ 30 appeals reached this level in 2016. The number has soared over the years. HHS doesn't easily share the numbers for the backlog.

• You have 60 days, from receipt of the decision by the administrative law judge, to file your request for a review by the Medicare Appeals Council.

A decision will usually be issued within 90 days. (23% are overturned) Due to an overwhelming number of Council review requests over the past several years, the Council has not been able to meet the 90-day time frame. There is a backlog.

♦ The Council provides the last level of review within the Department of Health and Human Services’ Medicare Advantage appeals process.

If you, providers, or the Plan are dissatisfied with the decision of the Council, they may appeal to Federal district court by filing a civil action.

Judicial Review in Federal District Court

• You must file an action in a Federal district court within 60 calendar days after the date you receive notice of the Council's decision.

♦ In order to request judicial review in Federal court, the amount remaining in controversy must meet a threshold requirement. For calendar year 2026, the amount in controversy must be more than $1,960 ($2,000 for reconsiderations issued by a Quality Improvement Organization). This amount is recalculated each year and may change.