Coverage type · Medicare
Medicare Advantage (Part C)
Medicare run through a private plan. Appeal to the plan first, within 65 days of the date on its denial notice. If a hospital stay, rehab or nursing care is ending, use the red box below: that clock is much shorter.
On this page 8
- Who has this
- People who get their Medicare coverage through a private company's plan instead of through Original Medicare.
- Who regulates it
- The Centers for Medicare & Medicaid Services sets the federal rules for Medicare Advantage plans. After the plan appeal, an independent review entity under contract with that agency reviews the case.
- Can your state help?
- Partly. The appeal steps are federal, so your state insurance department does not run them. Your state's State Health Insurance Assistance Program gives free one-on-one Medicare counseling. Find it on your state page. Find your state.
How to tell this is your coverage
- Your denial arrives from your plan, not from Medicare. It is a written Notice of Denial of Medical Coverage (or Payment), also called the Integrated Denial Notice (Form CMS-10003).
- Your Medicare benefits come through a private plan that you joined, not directly from the federal government.
- Your plan can end your treatment early or cut it back. Any decision by the plan to refuse or pay for a service you believe should be covered, before, during or after the service, can be appealed.
The appeal steps, in order
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First appeal to your plan
Official name: Reconsideration (after an organization determination, the plan's first decision)
- Who decides
- Your Medicare Advantage plan. Someone not involved in the first decision must decide, and for a medical necessity denial a physician with the right expertise must reconsider.
- Your deadline
- 65 calendar days from the date on the denial notice. The regulation says 60 calendar days after you receive the notice and treats you as receiving it 5 calendar days after the date on the notice. The Centers for Medicare & Medicaid Services and Medicare.gov describe the same rule as 65 calendar days from the notice date. Late requests can be accepted for good cause. File as early as you can, and check the date on your notice, which controls.
- Their deadline
- 30 calendar days for a service you have not yet received; 60 calendar days for a request for payment; 7 calendar days for a Part B drug (a drug given in a doctor's office or outpatient setting); 72 hours if the request is expedited. The plan may extend the deadline for a service or an expedited request by up to 14 calendar days, but not for a Part B drug.
- What to send
- A written request, unless your plan accepts oral requests. An expedited request can be oral. You, your representative or your treating physician (after telling you) can file. Say what was denied and why you disagree, and attach records or a doctor's letter.
- If you lose, or hear nothing
- If the plan upholds its denial in whole or in part, or misses its deadline, it must send your case file to the independent review entity. You do not have to ask. If the plan dismisses your request (for example as late or invalid), you must ask the independent review entity yourself in writing.
- The rule
- 42 CFR 422.582, request for a standard reconsideration
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Independent review
Official name: Reconsideration by the Independent Review Entity
- Who decides
- C2C Innovative Solutions, Inc., the independent review entity under contract with the federal government, for requests it receives from 1 May 2026. MAXIMUS Federal Services handles requests received through 30 April 2026.
- Your deadline
- Nothing to file if your plan upheld its denial; the plan must forward your case. For a plan expedited case the file must go within 24 hours. Only if your plan dismissed your appeal do you file: in writing within 60 calendar days of the dismissal notice (the Centers for Medicare & Medicaid Services describes this as 65 calendar days from the notice date). Check the date on your notice, which controls.
- Their deadline
- The Centers for Medicare & Medicaid Services lists 72 hours if expedited, 30 calendar days before a service, 7 calendar days for a Part B drug and 60 calendar days for payment.
- What to send
- Nothing is required from you when your plan forwards the case. You can send your own evidence, such as a doctor's letter, to support the review.
- If you lose, or hear nothing
- If the independent review entity upholds the denial and enough money is in dispute, you can request a hearing before an Administrative Law Judge.
- The rule
- 42 CFR 422.590, timeframes and responsibility for reconsiderations
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Hearing
Official name: Administrative Law Judge hearing
- Who decides
- An Administrative Law Judge at the Office of Medicare Hearings and Appeals
- Your deadline
- 60 calendar days after you receive the independent review decision. The amount in dispute must be at least $200 for 2026 and 2027. When a plan refuses to provide a service, the projected value of the service is used. Check the date on your decision, which controls.
- Their deadline
- The later levels mirror Original Medicare. The regulation's target for a hearing decision in Original Medicare is 90 calendar days after the hearing request, unless extended or waived.
- What to send
- A written hearing request with a copy of the independent review decision and the evidence that supports your claim.
- If you lose, or hear nothing
- If the judge upholds the denial, you can ask the Medicare Appeals Council to review it.
- The rule
- 42 CFR 422.600, right to a hearing
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Appeals Council review
Official name: Medicare Appeals Council review
- Who decides
- The Medicare Appeals Council
- Your deadline
- 60 calendar days after you receive the judge's decision. Check the date on your decision, which controls.
- Their deadline
- The later levels mirror Original Medicare. In Original Medicare the Council is to act within 90 calendar days (180 calendar days if the case was moved up from the Office of Medicare Hearings and Appeals).
- What to send
- A written request saying which parts of the judge's decision you disagree with and why.
- If you lose, or hear nothing
- If the Council upholds the denial and enough money is in dispute, you can bring a civil action in federal court.
- The rule
- 42 CFR 422.608, Appeals Council review
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Federal court
Official name: Judicial review in federal district court
- Who decides
- A federal district court
- Your deadline
- 60 calendar days after you receive the Council's decision. The amount in dispute must be at least $1,960 for 2026. It rises to $2,000 for requests filed on or after 1 January 2027. Check the date on your decision, which controls.
- Their deadline
- The court sets its own schedule.
- What to send
- A civil action filed in court, which follows the court's own rules. Talk to a lawyer or a free legal aid program before this level.
- If you lose, or hear nothing
- This is the last level.
- The rule
- 42 CFR 422.612, judicial review
If waiting could harm your health
Ask your plan for an expedited (fast) decision or appeal if waiting could seriously jeopardize your life, health or ability to regain maximum function. The plan must decide a fast first request within 72 hours (24 hours for a Part B drug) and a fast appeal within 72 hours. The plan must expedite if your physician says waiting could do that harm, or if the plan itself finds it. If the plan refuses, it must tell you promptly and move your request to the standard timeframe; you can then file an expedited grievance, which the plan must answer within 24 hours. Hospital discharge: ask the Quality Improvement Organization for review no later than the day you are discharged; it decides within one calendar day after it has your records, and the plan has the burden of proof. If you ask in time, the plan stays financially responsible until noon of the day after the decision. Ending skilled nursing facility, home health or comprehensive outpatient rehabilitation facility services: ask the Quality Improvement Organization for a fast-track appeal by noon of the day after you receive the Notice of Medicare Non-Coverage. The numbered steps near the top of this page set it out. A late request is still accepted, but without the fast deadline or protection from charges. Check the date and time on your notice, which controls.
Free help for this coverage
- State Health Insurance Assistance Program (SHIP)
Free one-on-one Medicare counseling that is not connected to any insurance company. Find your local program at shiphelp.org or by calling 877-839-2675. Your state page lists your state's program.
- 1-800-MEDICARE
Call 1-800-633-4227 (text telephone 1-877-486-2048). If a complaint or appeal is unresolved, ask the representative to submit it to the Medicare Beneficiary Ombudsman.
- Quality Improvement Organization
Free fast appeals of hospital discharges and service endings, and quality-of-care complaints. Two organizations serve the country, Acentra Health and Commence Health. The numbers for each state group are listed on the Original Medicare coverage page.
- Medicare Rights Center helpline
A national nonprofit. Free helpline 800-333-4114, Monday to Friday (as listed in November 2026); Spanish is available by pressing 8. Help is by phone only, and the organization asks you not to send personal Medicare information online.
- Legal aid
Free civil legal help for people with low incomes. A program can advise you on an appeal, especially at the hearing level and beyond, but it cannot take every case. Your state page lists legal aid programs for your state.
Who this covers
This page is for people whose Medicare comes through a private plan, called a Medicare Advantage plan or Part C. If you have Original Medicare, see Original Medicare. If your denial is for a prescription drug, see Medicare drug plans. Use the Medicare appeal navigator to see your steps, or read the Medicare Advantage appeals guide.
If you are told your hospital stay, rehab, nursing care or home health is ending
- Find the notice. For a hospital stay it is the Important Message from Medicare. For skilled nursing, home health or rehabilitation care it is the Notice of Medicare Non-Coverage. The provider must give you the second one at least two days before services end.
- Call the Quality Improvement Organization today. This is the independent Medicare reviewer. Its phone number is on the notice. If you cannot find the notice, call 1-800-MEDICARE (1-800-633-4227) and ask for the reviewer for your state.
- Know your time limit. Hospital stay: ask no later than the day you leave. Skilled nursing, home health or rehabilitation care: ask by noon of the calendar day after you receive the notice. If the notice gives an earlier time, use the earlier one.
- Ask for a fast appeal. You can ask by phone. Write down the date, the time and the name of the person you spoke to. If nobody answers, leave a message and note the time.
- Know what happens next. The reviewer decides within one calendar day for a hospital stay, and by close of business the day after it has the information for the other services. The plan has the burden of proof, which means the plan must show the care should end.
- If you miss the time. A late request is still reviewed, but without the fast deadline or protection from charges. Call anyway.
See the fast appeals guide for a worked date example and the phone script for a fast Medicare appeal.
How to tell this is your coverage
The denial comes from your plan and says how to ask the plan to reconsider. The plan’s first decision (called an organization determination) can be a refusal to cover or pay, a cut to treatment you were already getting, or a failure to decide in time. All of these can be appealed.
Since 1 January 2026 the plan must decide a standard prior authorization request (approval before care) within 7 calendar days, not 14, for items and services. The plan may extend that by up to 14 calendar days in limited circumstances and must tell you in writing. This does not apply to drugs.
What does not apply to you
Your plan appeal comes first, and you do not file the independent review yourself, unless the plan dismisses your appeal.
Ordinary Medicare Advantage rules have no general right to keep a service going while you appeal. A special group of plans for people with both Medicare and Medicaid, called integrated plans, runs one combined appeal process and does continue benefits for both programs if you ask within 10 calendar days of the plan sending the denial notice (or before the effective date, if later). If you are in one of those plans, see Medicaid managed care and read your notice closely. Other plans for people with both programs appear to follow the ordinary rules for each program, but we could not confirm this, so read your notice closely.
If your doctor or hospital is in your plan’s network and the plan has already decided its payment and you owe nothing more, that payment decision is not part of your appeal rights.
Where people go wrong
- The 60-day or 65-day question. The regulation says 60 calendar days after you receive the notice, and you are treated as receiving it 5 calendar days after the notice date. The government describes that as 65 days from the notice date. A rule published on 23 April 2024 added this wording. Its stated effective date is 3 June 2024. We could not confirm the first date it applied to plans, which is generally described as 1 January 2025. Read the deadline printed on your own notice, and file early. Your notice controls.
- Waiting for the independent review. For a standard denial you do not ask for it. If the plan upholds its denial or misses its deadline, the plan sends the case. Only a plan dismissal is different: you must ask in writing.
- Believing the plan can use its own rules. Since 2024 a plan must follow Original Medicare coverage rules. It may add its own criteria only where Medicare’s are not fully established, and it must post them with the evidence.
- Not appealing at all. In an analysis of 2024 plan data by KFF, about 7.7% of the roughly 52.8 million prior authorization decisions were denied in whole or part, 11.5% of denials were appealed, and 80.7% of appeals were partly or fully overturned. This is a secondary analysis of plan-reported data. It describes what happened in 2024 and does not predict your result.
- Mixing up a grievance and an appeal. A grievance is a complaint such as rudeness or waiting times. File it within 60 days of the event; the plan must respond within 30 days, extendable by 14. It does not replace an appeal.
- Changing plans in the middle of treatment. A plan must give a person who joins while in an active course of treatment a transition period of at least 90 days without disrupting treatment or requiring new authorization, even if the provider is out of network. Once a plan approves a service through prior authorization, it may not later deny it for lack of medical necessity, and may reopen the approval only for good cause or reliable evidence of fraud or similar fault.
Free help is listed above. Name someone to act for you with the authorized representative letter.
Sources
- 42 CFR 422.566 and 422.568, organization determinations and deadlines
- 42 CFR 422.570 and 422.572, expedited decisions
- 42 CFR 422.582, request for a standard reconsideration
- 42 CFR 422.590, timeframes and responsibility for reconsiderations
- 42 CFR 422.592, reconsideration by the independent entity
- 42 CFR 422.600, 422.602, 422.608 and 422.612, later appeal levels
- 42 CFR 422.620 to 422.626, fast appeals of discharges and service endings
- 42 CFR 422.564, grievances
- 42 CFR 422.101, coverage criteria and medical necessity
- 42 CFR 422.138, prior authorization
- 42 CFR 422.112, continuity of care
- CMS, reconsideration of a Medicare Advantage plan decision
- CMS, Part C independent review entity
- Medicare.gov, appeals in a Medicare health plan
- Federal Register, rule CMS-4201-F3 and CMS-4205-F (23 April 2024)
- Federal Register notice CMS-4213-N, amount in controversy threshold amounts (2026-19016, 16 September 2026)
- CMS fact sheet, Interoperability and Prior Authorization final rule (CMS-0057-F)
- KFF, Medicare Advantage insurers made nearly 53 million prior authorization determinations in 2024
- 42 CFR 422.629 and 422.633, integrated plans for people with Medicare and Medicaid