The five appeal levels
Checked against the current rules on September 21, 2026.
A Medicare Advantage denial can move through up to five levels of review. Most cases resolve at the first or second — but knowing the whole ladder helps you understand where your case actually is, and what's next if it keeps going.
Level 1 — Ask the plan to reconsider
Decided by: The plan itself (the same Medicare Advantage organization that denied it).
65 days from the date on the notice. The rule (42 CFR § 422.582) gives you 60 days from when you receive the denial, and receipt is presumed to be 5 days after the notice's own date unless shown otherwise — 60 + 5 = 65 days from the notice date.42 CFR 422.582
The plan must decide within 30 calendar days for a request about a service you haven't received yet, 60 calendar days for a request about payment for something already provided, or 72 hours if the request is expedited (42 CFR § 422.590).
If the plan upholds its denial, in whole or in part, it must automatically send your case to the Independent Review Entity — you don't have to do anything to trigger this (42 CFR § 422.590).
Where to send it: Wherever the notice itself says to send a reconsideration request — there is no separate CMS form at this level (42 CFR § 422.582).
Level 2 — Independent Review Entity (IRE)
Decided by: An independent outside entity under contract with CMS — currently C2C Innovative Solutions, effective May 1, 2026 — not the plan (42 CFR § 422.592).
Automatic. The plan is required to forward your case to the IRE itself once it upholds its own denial — you don't file anything to reach this level.42 CFR 422.592
The IRE must decide within 30 calendar days for a service/item request, 60 calendar days for payment, 7 calendar days for a Part B drug request, or 72 hours if expedited — the same timeframes as Level 1 (CMS Parts C & D Appeals Guidance § 60.3).
If the IRE's decision doesn't fully reverse the denial, its notice must explain your right to an Administrative Law Judge (ALJ) hearing and how to request one (42 CFR § 422.594).
Where to send it: Nothing to send at this level — the plan forwards your case file to the IRE directly. You may submit additional evidence to the IRE yourself.
Level 3 — Administrative Law Judge (ALJ) hearing
Decided by: An Administrative Law Judge or attorney adjudicator at the Office of Medicare Hearings and Appeals (OMHA).
60 days from receiving the IRE's decision notice (42 CFR § 422.602).42 CFR 405.1002
OMHA sets the specific date and time for your hearing after you file; there's no fixed decision deadline stated in the corpus for this level.
The dollar amount still in dispute must meet a yearly minimum set by the Secretary — $200 for 2026 — to qualify for an ALJ hearing (42 CFR § 422.600).
None — you must actively request a hearing; it does not happen automatically.
Where to send it: The entity named in the IRE's own reconsideration notice (42 CFR § 422.602).
Level 4 — Medicare Appeals Council review
Decided by: The Medicare Appeals Council, part of HHS's Departmental Appeals Board.
60 days from the ALJ's or attorney adjudicator's decision (42 CFR § 422.608).42 CFR 405.1102
The Council reviews the ALJ's record; no fixed decision deadline is stated in the corpus for this level.
None — you must actively request Council review.
Where to send it: The Departmental Appeals Board, following the instructions printed in the ALJ's decision (42 CFR § 422.608).
Level 5 — Federal district court
Decided by: A judge in a United States district court.
60 days from the Council's decision (or from the ALJ's decision, if the Council declined to review it) (42 CFR § 422.612).42 CFR 405.1130
Set by the court, the same as any federal civil case.
The dollar amount still in dispute must meet a yearly minimum set by the Secretary — $1,960 for 2026 (42 CFR § 422.612).
Where to send it: A United States district court, by filing a civil action under section 205(g) of the Social Security Act (42 CFR § 422.612).
Questions people ask
- Do I have to go through every level in order?
- Yes — each level is reached only after the one before it, except Level 2 (the Independent Review Entity), which the plan is required to trigger automatically once it upholds its own denial.
- What if I miss a deadline?
- Every level with a filing deadline allows a late filing for good cause — a serious illness, a family emergency, or not having received the notice, for example.
Sources — last checked September 21, 2026
- 42 CFR 405.1002as of September 21, 2026
- 42 CFR 405.1102as of September 21, 2026
- 42 CFR 405.1130as of September 21, 2026
- 42 CFR 422.582as of September 18, 2026
- 42 CFR 422.592as of September 18, 2026
Related
Not sure what applies to your case?
Upload your denial letter and get a free, plain-language explanation with your real deadline.
By CaseWhy Appeals editorial. See how this content is produced. Not legal advice. Not affiliated with or endorsed by Medicare, CMS, or any health plan. A product of CaseWhy LLC.
