Independent Review Entity (IRE) decision: what it means and what to do

A decision from the outside reviewer that automatically reviews a plan's unfavorable reconsideration.

An Independent Review Entity (IRE) decision comes from the outside reviewer under contract with CMS — not the plan — that automatically reviews any reconsideration the plan didn't fully grant.

If the IRE's decision doesn't fully reverse the denial, its notice has to explain your right to an Administrative Law Judge hearing and how to request one.rule42 CFR 422.594

The IRE reviews the case independently — it isn't simply rubber-stamping the plan's own reconsideration, and its reviewers weren't involved in the original decision. A meaningful share of these reviews do overturn the plan, which is exactly why the automatic-forward requirement exists in the first place.

Moving to an ALJ hearing is the first level that isn't automatic — you have to actively request it, and the case has to meet a minimum dollar amount still in dispute. Both of those are worth confirming before you file.

The IRE decision notice itself is required to explain both the outcome and, if it wasn't a full reversal, the specific steps to request an ALJ hearing — that notice, not a general search, is the authoritative source for exactly where and how to file at this level.

An ALJ hearing is usually held by phone or video, not in person — worth knowing so the format itself isn't an added source of stress on top of the case. You, a representative, or both can take part.

As with the reconsideration decision before it, read the IRE's outcome carefully — a partial reversal changes what's actually left to argue if the case moves on to a hearing.

Read the outcome. The notice states whether the independent reviewer reversed the plan's denial, in whole or in part, or upheld it.

If upheld, you may request an ALJ hearing. 60 days from receiving the IRE's decision notice (42 CFR § 422.602).

Check the dollar threshold. 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).