Medicare Advantage
Medicare Advantage appeal: the 5 levels, explained
Medicare Advantage denials go through up to five appeal levels, and the second one happens automatically. If your plan upholds its own denial, the case gets forwarded to an independent reviewer without you having to ask. Here's what each level does, how long it takes, and how often these denials actually get overturned.
The 5 levels
Medicare Advantage appeals move through a fixed sequence, each one a check on the level before it.
- Plan reconsideration, your first appeal, filed directly with your Medicare Advantage plan.
- Independent Review Entity, currently Maximus. If the plan upholds its denial, this level happens automatically. You don't file anything to trigger it.
- Administrative Law Judge hearing through OMHA, available once the disputed amount meets a minimum dollar threshold.
- Medicare Appeals Council, a further review of the judge's decision.
- Federal court, the final level, available once the disputed amount meets a higher threshold.
Why level 2 matters more than people realize
Most appeal processes require you to actively request each subsequent level yourself, and people lose their case simply by not knowing that the next step exists. Medicare Advantage works differently at this one point: if your plan reconsideration is denied, the case is automatically forwarded to the Independent Review Entity, currently operated by Maximus, for an independent look. You get a genuinely independent reviewer, at no cost to you and no extra paperwork, built into the process by default.
That doesn't mean you can skip preparing a strong reconsideration request. The independent reviewer looks at the same file and the same clinical argument you submitted the first time, so the quality of your initial appeal still determines the outcome. It just means you're not required to chase down a second filing to get an outside opinion.
Deadlines at each level
| Level | File within | Decision within |
|---|---|---|
| 1. Plan reconsideration | 60 days (some notices say 65; use the number on your notice) | Pre-service: 30 days. Payment disputes: 60 days. Expedited: 72 hours. |
| 2. Independent Review Entity (Maximus) | Automatic on an upheld denial, no filing needed | 30 days standard, 72 hours expedited |
| 3. Administrative Law Judge (OMHA) | 60 days; amount in dispute must be at least $200 (2026) | Roughly 90 days, as a target |
| 4. Medicare Appeals Council | 60 days | Roughly 90 days, as a target |
| 5. Federal court | 60 days; higher dollar threshold applies | Not tracked at a standard timeframe |
The 90-day figures at levels 3 and 4 are processing targets, not guarantees, and real timelines can run longer. As with every stage of every appeal, the deadline on your actual notice controls, not the general numbers in this table.
Published overturn rates
Independent data on Medicare Advantage appeals shows something worth knowing before you decide whether to fight a denial: appeals that make it to review get overturned often.
Of Medicare Advantage prior-authorization denials appealed in 2024 were fully or partially overturned. Source: KFF's Medicare Advantage prior-authorization analysis.
Overturn rates for post-acute care appeals by setting: skilled nursing facility (SNF), long-term care hospital (LTCH), and inpatient rehab facility (IRF). Source: HHS Office of Inspector General, 2026.
Those post-acute numbers are the most striking figures in Medicare Advantage appeals data. Skilled nursing facility denials in particular get overturned at a very high rate once appealed, which means if your denial involves a SNF stay, rehab facility, or long-term care hospital, it deserves priority. These figures describe past outcomes for appealed cases generally. They aren't a prediction for any individual claim, and no one can promise you a specific result.
What to actually do with this
Build your plan-reconsideration appeal as if it's the only chance you'll get, since the independent review at level 2 works from the same record. Get your treating physician's letter addressing medical necessity, request the plan's specific coverage criteria for the denied service, and match your documentation to it element by element. If your denial involves post-acute care, that documentation effort is especially worth the time given how often those specific denials get reversed on appeal.
If waiting the standard timeframe would seriously jeopardize your health, ask for an expedited decision at level 1. Your physician's support for that request matters, so get it in writing and attach it to the reconsideration itself rather than mentioning it separately. Expedited requests get a 72-hour decision instead of the standard 30 or 60 days, and the same expedited handling carries through if the case is automatically forwarded to the Independent Review Entity.
If someone is appealing on your behalf
Medicare requires a specific written authorization for someone else to act as your representative in the appeal, CMS Form 1696, which stays valid for one year. This is separate from a general medical power of attorney or a HIPAA release, and plans and reviewers will look for it specifically before dealing with a representative on the record. Have it signed and ready before the representative files anything.
If your case involves a representative and reaches the Administrative Law Judge level or higher, charging you a fee for that representation becomes subject to a formal fee-approval process, a petition filed with the Office of Medicare Hearings and Appeals. Representation at the plan reconsideration or Independent Review Entity level isn't subject to that requirement, which is one more reason a well-built level-1 appeal is worth the effort: it's the stage where help is least encumbered by that rule.
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Sources
- KFF, Medicare Advantage prior-authorization and appeals analysis (2024 data): 80.7% overturn rate for appealed prior-authorization denials.
- HHS Office of Inspector General (2026): post-acute care appeal overturn rates by setting (SNF, LTCH, IRF).
- 42 CFR 405.910: Medicare authorized representative rules, including CMS Form 1696 and fee-approval requirements at the ALJ level and above.