Reconsideration decision: what it means and what to do

The plan's written decision after you asked it to reconsider a denial.

A reconsideration decision is the plan's written answer after you asked it to reconsider its own denial — this is the outcome of Level 1 of the appeal process.

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.rule42 CFR 422.590

A reconsideration decision can go three ways: the plan fully reverses its own denial (the case is over, in your favor), it partially reverses (some of what you asked for is granted), or it upholds the original denial. Only a full reversal ends the appeal — anything less still moves automatically to the next level.

There's nothing to file at this point if the plan upheld its decision. The forwarding to the Independent Review Entity is the plan's own legal obligation, not something that depends on the family taking action — the case simply continues on its own.

If the reconsideration is unclear about which of the three outcomes actually happened, that's worth calling the plan to confirm directly — knowing exactly where the case stands changes whether there's anything for you to do right now or whether it's simply moving on its own.

Keep this decision with your other case paperwork — the Independent Review Entity's own review will reference it directly, and having it on hand saves time if you're asked about it.

A partial reversal is still worth reading carefully — knowing exactly what was and wasn't granted matters for whether there's anything left to pursue at the next level.

Read the outcome. The notice states whether the plan reversed its own denial, in whole or in part, or upheld it.

If upheld, nothing to file. 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.

Prepare while it's automatic. Use the time the automatic forward takes to gather any additional evidence you want the independent reviewer to see.