The four appeal levels
Checked against the current rules on September 24, 2026.
A PACE (Program of All-Inclusive Care for the Elderly) denial can move through up to four 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 0 — Service determination request
Decided by: The PACE organization's interdisciplinary team.
No deadline to make this first request — a participant, their designated representative, or their caregiver may request it at any time, orally or in writing.42 CFR 460.121
As expeditiously as the participant's condition requires, but no later than 3 calendar days from the request — extendable by up to 5 calendar days.
Where to send it: Any employee or contractor of the PACE organization who provides direct care, the PACE center, or while transporting participants.
Level 1 — PACE organization appeal
Decided by: An impartial third-party reviewer or review committee, not involved in the original decision.
No filing deadline is stated in the corpus for this level — the PACE organization's own written appeals process states its specific procedure.42 CFR 460.122
As expeditiously as the participant's health condition requires, but no later than 30 calendar days standard, or 72 hours if expedited — extendable by up to 14 calendar days.
Where to send it: The PACE organization, per its own written appeals process.
Level 2 — Independent Review Entity (IRE) reconsideration
Decided by: C2C Innovative Solutions, Inc., the Independent Review Entity under contract with CMS.
60 calendar days from the date of the PACE organization's own appeal decision. Written request required.42 CFR 460.124
As expeditiously as the participant's health condition requires, but no later than 30 calendar days standard (extendable by 14 days for a request for information) or 72 hours if expedited.
Where to send it: C2C Innovative Solutions, Inc. — QIC Part C, P.O. Box 1949, Jacksonville, FL 32231-0053.
Level 2 — State fair hearing
Decided by: Your state's own Medicaid fair-hearing office.
Set by your state's own fair-hearing rules (42 CFR Part 431, Subpart E) — check your state's own notice for the exact deadline.42 CFR 460.124
Set by your state's own fair-hearing process.
Where to send it: Your state's own Medicaid fair-hearing office.
Questions people ask
- Do I have to go through every level in order?
- Yes — each level is reached only after the one before it.
- 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 24, 2026
- 42 CFR 460.121as of September 24, 2026
- 42 CFR 460.122as of September 24, 2026
- 42 CFR 460.124as of September 24, 2026
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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.
