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Medicare Advantage: Coverage Decisions and Appeals

Adapted from Medicare Appeals, Centers for Medicare & Medicaid Services. The selected guidance concerns Medicare coverage and payment, not a recommendation for medical treatment. Numbered page references below refer to the linked source publication.

Coverage can depend on medical necessity, the setting, provider participation, and your plan’s rules. Use the cited publication for the full conditions and check the plan year when comparing costs or enrollment choices.

File an appeal with a Medicare Health Plan

Medicare Advantage Plans and Medicare Cost Plans are health plan options approved by Medicare and run by private companies. When you join a Medicare Advantage Plan or other Medicare health plan, you’re still in Medicare.

If you have a Medicare Advantage Plan or other Medicare health plan, you have the right to ask your plan to provide or pay for items or services you think it should cover, provide, or continue. You also have the right to ask for an appeal to resolve differences with your plan. Your Medicare Advantage Plan or other Medicare health plan will send you information that explains your rights. Call your plan if you have questions.

Medicare Cost Plans are types of Health Maintenance Organizations (HMOs) available in certain areas of the country. If you have a Medicare Cost Plan and want to appeal services you got outside of the plan’s network, you’ll follow the Original Medicare appeals process. Go to page 5.

If you’re in a Program of All-inclusive Care for the Elderly (PACE), your appeal rights may be different. The PACE organization will give you written information about your appeal rights.

If you decide to file an appeal, ask your doctor, other health care provider, or supplier for any information that may help your case. Keep a copy of everything you send to your plan as part of your appeal.

How do I file an appeal in a Medicare Advantage Plan?

Request an organization determination

You have the right to ask your plan to provide or pay for items, services, or Part B drugs you think it should cover, provide, or continue. The decision by the plan is called an “organization determination.” You, your representative, or your health care provider can ask for an organization determination from your plan in advance to make sure that the services are covered. Your plan must process your request for advance coverage within 72 hours for Part B drugs, 7 days for items and services that your plan requires prior authorization, or 14 days for all other items and services. These organization determinations must be processed as quickly as your health requires. In some cases, the time to complete appeals may be extended by up to 14 days. (For example, if your plan needs more information from a non-contract provider to make a decision about your case, and the extension is in your best interest.) Your plan will notify you in writing if it decides to take an extension, why, and your rights if you disagree with their decision.

If you think your health could be seriously harmed by waiting the standard timeframe for a decision, depending on the type of request (or 72 hours for a request for Part B drugs), ask your plan for a fast or “expedited” decision. The plan must tell you of its decision within 24 hours for Part B drugs or 72 hours for items and services when it determines, or your doctor tells your plan, that waiting for a standard decision may seriously jeopardize your life, health, or ability to regain maximum function.

After you get an item, service, or Part B drug that you think your plan should cover, you or your health care provider may ask your plan pay for it. Your plan must process these payment requests within 60 days.

If the plan won’t cover the items, services, or Part B drugs you asked for, you’ll get a notice explaining why your plan fully or partially denied your request, and instructions on how to appeal your plan’s decision by asking for a reconsideration. If you appeal the plan’s decision, you may want to ask for a copy of your file containing medical and other information about your case. Your plan may charge you for this copy.

If you disagree with your plan’s organization determination, you can file an appeal. The appeals process has 5 Levels:

Level 1: Reconsideration from your plan Level 2: Review by an Independent Review Entity (IRE) Level 3: Decision by the Office of Medicare Hearings and Appeals (OMHA) Level 4: Review by the Medicare Appeals Council (Appeals Council) Level 5: Judicial Review in a Federal District Court

If you disagree with the decision made at any level of the appeals process, you can generally go to the next level. At each level, you’ll get instructions on how to move to the next level of appeal.

Level 1: Reconsideration from your plan

Level 1 appeals in a Medicare Advantage Plan are called “Health Plan Reconsiderations.” If you disagree with the initial decision from your plan, you or your representative can ask for a reconsideration. Follow the directions in the plan’s initial denial notice and plan materials to start your appeal. If your appeal is for a service you haven’t gotten yet, your doctor can ask for a reconsideration on your behalf (and must notify you about it).

You, or your representative, must file an appeal within 65 days from the date on the initial denial notice sent by your plan. If you miss the deadline, you must give a reason for filing late.

Include this information in your appeal:

Your name, address, and the Medicare Number on your Medicare card
The items or services you’re appealing, the dates of service, and the reason(s) why you’re appealing.
The name of your representative and proof of representation, if you’ve appointed a representative.
Any other information (like a doctor’s note) to make your appeal stronger.

You should also include any other information that may help your case. Keep a copy of everything you send to your plan as part of your appeal.

If you think your health could be seriously harmed by waiting the standard processing time for a decision, ask your plan for a fast or “expedited” appeal. The plan must give you its decision within 72 hours if it determines, or your doctor tells your plan, that waiting for a standard decision may seriously jeopardize your life, health, or ability to regain maximum function.

How long your plan has to respond to your initial appeal depends on the type of appeal you’re filing:

Standard process:

Pre-service appeal: 30 days*
Payment appeal: 60 days
Part B drugs appeal: 7 days*

Fast appeal: 72 hours *These reconsiderations must be processed as quickly as your health requires.

The time to complete appeals may be extended by up to 14 days in some cases. (For example, if your plan needs more information from a non-contract provider to make a decision about your case, and the extension is in your best interest.) Your plan will notify you in writing if it decides to take an extension, why, and your rights if you disagree with their decision.

If the plan decides against you (fully or partially), your appeal is automatically sent to Level 2.

Level 2: Review by an Independent Review Entity (IRE)

If your plan upholds their denial in your Level 1 appeal, they’ll automatically forward their reconsideration decision to an Independent Review Entity (IRE) to start a Level 2 appeal.

How long the IRE has to respond depends on the type of appeal.

Standard process:

Pre-service appeal: 30 days
Payment appeal: 60 days
Part B drugs: 7 days

Fast appeal: 72 hours The time to complete appeals may be extended by up to 14 days in some cases. For example, if the IRE needs more information from your plan to make a decision about the case, and the extension is in your best interest. The IRE will notify you in writing if it decides to take an extension.

You’ll get a fast decision if the IRE determines that your life or health may be at risk by waiting for a decision.

If you disagree with the IRE’s decision in Level 2: You have 60 days from the date you get the IRE’s decision to ask for a Level 3 appeal, which is a decision by OMHA.

Level 3: Decision by the Office of Medicare Hearings and Appeals (OMHA)

If you file an appeal with OMHA, the amount of your case must meet a minimum dollar amount. For 2026, the minimum dollar amount is $200.

You can ask for a hearing before an Administrative Law Judge (ALJ) or, in certain circumstances, if you don’t want to have a hearing, you can ask for an on-the-record review of your appeal by an ALJ or attorney adjudicator. To ask for a hearing before an ALJ, follow the directions on the “Medicare Reconsideration Notice” you got from the IRE in your Level 2 appeal.

A hearing before an ALJ allows you to present your appeal to a new person who will independently review the facts of your appeal and listen to your testimony before making a decision. An ALJ hearing is usually held by phone or video-teleconference, but can also be held in person if the ALJ finds that you have a good reason.

You or your representative can ask for a hearing in one of these ways:

Fill out a “Request for Medicare Hearing by an Administrative Law Judge” form.
Submit a written request, which must include:
Your name, address, phone number, and Medicare Number. If you’ve appointed a representative, include the name, address, and phone number of your representative.
The appeal number assigned by the IRE if any.
The dates of service for the items or services you’re appealing.
Why you disagree with the IRE’s decision.
Any information to make your appeal stronger. If you can’t include this information with your request, include a statement explaining what you plan to submit and when you’ll submit it.

File an appeal online with OMHA by visiting HHS-ecape-portal.entellitrak.com.

Get more information about the ALJ hearing process at HHS.gov/about/agencies/ omha/filing-an-appeal/faqs/requesting-an-alj-hearing, or call us at 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048.

How do I ask for a review of my case without a hearing?

You can ask OMHA to make a decision without holding a hearing (based only on the information that’s in your appeal record). The ALJ or attorney adjudicator may also issue a decision without holding a hearing if the appeal record supports a decision that’s fully in your favor.

To ask OMHA to make a decision without a hearing (based on only the information that’s in your appeal record), submit the information required for an ALJ hearing (listed above) and one of these:

The”Waiver of Right to an Administrative Law Judge (ALJ) Hearing” form (Form OMHA-104). To download the form, visit HHS.gov/about/agencies/omha/filing-an-appeal/forms.
A written request stating that you don’t wish to appear before an ALJ at a hearing (including a hearing held by phone or video-teleconference).

Even if you waive the ALJ hearing, a hearing may still be held by an ALJ if the other parties in your case who were sent a notice of hearing (for example, your provider) don’t also waive the ALJ hearing, or if the ALJ believes a hearing is necessary to decide your case.

If you asked OMHA for a decision without a hearing, but the ALJ decides a hearing is necessary, the ALJ will let you know when the hearing will be. If no hearing is held, either an ALJ or attorney adjudicator will review the information in your appeal record and make a decision.

You can ask to move to appeals Level 4 if:

OMHA doesn’t issue a timely decision.
You disagree with the OMHA’s decision.

You have 60 days after you get the decision to ask for appeals Level 4. You’ll follow the directions in the ALJ’s hearing decision.

Level 4: Review by the Medicare Appeals Council

You can ask that the Medicare Appeals Council review your case regardless of the dollar amount.

You can ask for the Medicare Appeals Council (Appeals Council) review in 1 of 2 ways:

Fill out a “Request for Review of an Administrative Law Judge (ALJ) Medicare Decision/Dismissal” form: HHS.gov/sites/default/files/dab101.pdf.
Submit a written request to the Appeals Council that includes:
Your name and Medicare Number. If you’ve appointed a representative, include the name of your representative.
The specific item(s) and/or service(s) and specific date(s) of service you’re appealing.
A statement describing what you disagree with in the ALJ’s decision and why.
The date of the ALJ decision.
If you’re asking that your case be moved from the ALJ to the Appeals Council because the ALJ hasn’t issued a timely decision, send your ask to the OMHA address listed on the IRE’s reconsideration notice (or, if you know that your case was assigned to an OMHA adjudicator, to the hearing office where it’s pending).

For more information about the Medicare Appeals Council review process, visit HHS.gov/about/agencies/dab/different-appeals-at-dab/appeals-to-council, or call us at 1-800-MEDICARE (1-800-633-4227).

Level 5: Judicial Review in a Federal District Court

You can request judicial review in Federal district court (level 5) if:

The Appeals Council doesn’t issue a timely decision.
You disagree with the Appeals Council’s decision in Level 4.
The amount of your case meets a minimum dollar amount. For 2026, the minimum dollar amount is $1,960. You may be able to combine claims to meet this dollar amount.

You have 60 days after you get the Appeals Council’s decision to ask for judicial review by a federal district court.

How do I request a review?

Follow the directions in the Appeals Council’s decision letter you got in Level 4 to file a complaint in Federal District Court.

For more information on the appeals process

Visit Medicare.gov/providers-services/claims-appeals-complaints/appeals/ medicare-health-plans.
Call 1-800-MEDICARE (1-800-633-4227). TTY users can call 1-877-486-2048. Visit Medicare.gov/basics/forms-publications-mailings/forms/appeals for appeal forms.
Call your State Health Insurance Assistance Program (SHIP) to get help with appeals. To get the phone number for the SHIP in your state, visit shiphelp.org, or call 1-800-MEDICARE.

How do I file a complaint (grievance)?

If you have concerns or problems with your Medicare Advantage Plan or other Medicare health plan that don’t involve providing or paying for items or services, you can file a complaint, also known as a grievance.

If your concern involves the quality of care you got or are getting, you can file a complaint with your plan and/or your BFCC-QIO. You can visit CMS.gov/medicare/ quality/quality-improvement-organizations/family-centered-care or call 1-800-MEDICARE to get the BFCC-QIO’s phone number.
For example, you may file a complaint with your Medicare health plan if:
You believe your plan’s customer service hours of operation should be different.
You believe there aren’t enough specialists in the plan to meet your needs (but you’re not asking to visit an out-of-network specialist, which requires an organization determination).
The company offering your plan is sending you materials that you didn’t ask to get and aren’t related to your plan.
The plan didn’t make a decision about a reconsideration within the required timeframe.
The plan didn’t send your case to the IRE.
You disagree with the plan’s decision not to grant your request for a fast appeal, or you disagree with the plan’s decision to extend the timeframe for making its decision.
The plan didn’t provide the required notices.
The plan’s notices don’t follow Medicare rules.

When you join a Medicare Advantage Plan or other Medicare health plan, the plan will send you information about how to file complaints in its membership materials. Read the information carefully, and keep it where you can find it if you need it. Call your plan if you have questions.

Source and further reading

Medicare Appeals — Centers for Medicare & Medicaid Services. Public domain U.S. government educational material, accessed October 28, 2026. Fynoptic has selected sections, removed print navigation, and reformatted the text for this guide. The agency does not endorse Fynoptic.

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