When your Medicare Advantage plan denies a claim or pre-authorization request, you have the right to appeal through a five-level process. Start by requesting reconsideration from your plan within 60 days of receiving the denial notice. The plan must respond within 72 hours for expedited requests or 30 days for standard requests.
If your plan upholds the denial, your case automatically advances to level two, where an Independent Review Entity reviews the decision using the same response timeframes. If they also deny your appeal, you can request a hearing before an Administrative Law Judge at level three if the disputed amount meets the minimum threshold, which is $200 for 2025.
Level four involves review by the Medicare Appeals Council, and level five allows you to file in federal district court if the amount exceeds $2,000 for 2025. These threshold amounts are adjusted annually and will change for 2026.
Throughout the appeals process, you have the right to representation and can designate someone to appeal on your behalf. For urgent situations where delays could jeopardize your health, request an expedited appeal. Your plan must decide within 72 hours.