Overview: Appeal Structures Across Programs
Every government-sponsored health program in the U.S. provides members with an appeal process when coverage is denied or benefits are reduced. The structure differs by program—Original Medicare, Medicare Advantage (Part C), Part D, Medicaid, and the Marketplace each have distinct appeal ladders with different decision-makers and timelines.
A core principle applies across all programs: members receive a notice when a benefit is denied or coverage ends, and that notice includes information about how and when to appeal. Professionals working with members—case managers, navigators, advocates, brokers—should be familiar with these structures to advise members on timing, options, and whether expedited (fast) review is available.
Original Medicare (Fee-for-Service) Appeals
Original Medicare has a five-level appeal structure administered by Centers for Medicare & Medicaid Services (CMS) and its contractors.
The Five Levels
- Level 1: Redetermination by the Medicare Administrative Contractor (MAC). The MAC (your region's Medicare contractor) reviews the claim or coverage decision. Members file within a deadline stated on the notice. The MAC issues a decision within a set timeframe.
- Level 2: Reconsideration by a Qualified Independent Contractor (QIC). If the member disagrees with the MAC's redetermination, an independent QIC (not the MAC) conducts a new review. This step is required before escalating to an ALJ.
- Level 3: Administrative Law Judge (ALJ) Hearing (OMHA). If the QIC upholds the MAC's decision, members can request a hearing before an Administrative Law Judge at the Office of Medicare Hearings and Appeals (OMHA). ALJs have authority to reverse or uphold prior decisions.
- Level 4: Medicare Appeals Council (MAC). If unsatisfied with the ALJ's decision, members can request review by the Medicare Appeals Council, which may affirm, reverse, or remand the case.
- Level 5: Federal Court. If all prior levels are exhausted, members may file suit in federal district court, typically for claims exceeding a CMS-set threshold amount.
Timeframes and Expedited Track
Each level has specific filing deadlines (typically 60 or 180 days from the notice) and decision timelines (decision times vary by level). The standard track follows the full timeline for each stage. When a member's health or ability to function is at immediate risk, they may request an expedited (fast) review, which shortens decision times significantly—sometimes to as little as 24–72 hours at the earliest levels. Expedited eligibility depends on medical urgency; not all claims qualify.
Medicare Advantage (Part C) Appeals
Medicare Advantage plans are required to follow a specific appeal process, then connect to CMS-administered levels if the plan's decision stands.
Plan-Level Appeal → External Review → Federal Appeal Levels
- Plan Reconsideration (Internal Appeal). The plan reviews a denied claim or coverage decision. Members typically have 60 days from the denial notice to request reconsideration. The plan must respond within 30 days (or expedited 24 hours if health is at risk).
- Independent Review Entity (IRE). If the plan upholds its decision, the member's appeal is automatically forwarded to an IRE—an independent contractor hired by CMS to review MA appeals. The IRE is not affiliated with the plan. Standard decisions: up to 30 days; expedited: up to 72 hours.
- Administrative Law Judge (ALJ), Medicare Appeals Council, and Federal Court. If the IRE agrees with the plan, members may escalate to an ALJ hearing, then the Medicare Appeals Council, and finally federal court (following the same path as Original Medicare levels 3–5).
Fast-Track for Urgent Situations
If a member's health or ability to obtain necessary services is at risk, the plan must conduct an expedited reconsideration (24 hours); if the plan denies expedited review, the appeal automatically goes to the IRE for expedited review (72 hours). This fast-track can bypass time delays at earlier stages when medical urgency is documented.
Part D (Prescription Drug) Appeals
Part D plans (offered by Medicare Advantage or as standalone PDP) follow a similar ladder: plan-level appeal, then external review, then federal levels.
The Appeal Path
- Coverage Determination / Reconsideration by the Plan. Members request a coverage determination (e.g., to override a formulary exclusion or tier placement) or reconsider a denial. Timelines: 72 hours for standard requests, 24 hours for expedited requests when health is at risk.
- Independent Review Entity (IRE). If the plan denies or partially approves the request, the appeal moves to an IRE. Standard decision: up to 30 days; expedited: 72 hours.
- ALJ, Appeals Council, Federal Court. If the IRE upholds the plan's position, members may request an ALJ hearing, then appeal to the Medicare Appeals Council and federal court.
Medicaid Appeals (State Fair Hearings)
Medicaid appeals vary significantly by state because Medicaid is jointly funded and administered by states and the federal government. There is no single national Medicaid appeals structure.
Typical Medicaid Appeal Path
- Plan-Level Appeal (Managed Care). If a member is in a Medicaid managed-care plan, the plan's internal appeal process usually comes first. Timelines and procedures vary by state and plan.
- State Fair Hearing. Members may request a fair hearing before a state-designated hearing officer or administrative law judge. This is the primary external appeal in Medicaid. Timelines, procedures, and available remedies differ by state. Some states require exhaustion of the plan appeal before a fair hearing; others allow concurrent appeals.
- Appeal Within Medicaid Administration. Some states have additional steps within their Medicaid agency before or after a fair hearing.
- Legal Action. Members or advocates may pursue judicial review or federal civil rights complaints through HHS Office for Civil Rights.
Because Medicaid rules are state-specific, professionals must consult the relevant state Medicaid agency website and the member's plan materials for exact deadlines and procedures. See State Directory for links to state Medicaid agencies.
Marketplace (ACA Exchange) Appeals
Marketplace plans, whether on Healthcare.gov or state exchanges, are not administered by CMS appeals contractors but by the exchange itself and the insurer.
Exchange-Level Appeal
- Members request appeal through the exchange (Healthcare.gov or state exchange). The exchange or plan conducts a review of eligibility, subsidy, or coverage decisions.
- Timeframes vary by exchange and decision type.
- If dissatisfied, members may pursue further review under state insurance laws or file a complaint with the state insurance commissioner.
Marketplace appeals are more limited in scope compared to Medicare and Medicaid, focusing primarily on eligibility and subsidy determinations rather than medical necessity denials.
Appeal Timelines at a Glance
The table below summarizes the primary appeal levels and typical decision timeframes. Note: exact day counts vary by program, state, and claim type, and timelines change with regulatory updates. Use this as a reference framework and verify current timelines with the relevant official source.
| Program | Level 1 | Level 2 | Level 3+ | Expedited Track Available? |
|---|---|---|---|---|
| Original Medicare (FFS) | Redetermination by MAC; typically 60 days to file | Reconsideration by QIC; typically 60 days to file | ALJ (OMHA), Appeals Council, Federal Court | Yes, 24–72 hours for expedited at Levels 1–2 |
| Medicare Advantage | Plan Reconsideration; 60 days to request, 30-day decision | Independent Review Entity (IRE); automatic forward, 30-day decision | ALJ, Appeals Council, Federal Court | Yes, 24 hours (plan), 72 hours (IRE) for urgent health issues |
| Part D | Plan Coverage Determination/Reconsideration; 72-hour decision | Independent Review Entity (IRE); 30-day decision | ALJ, Appeals Council, Federal Court | Yes, 24 hours (plan), 72 hours (IRE) for urgent requests |
| Medicaid | Plan Appeal (if managed care); state-specific timeline | State Fair Hearing; state-specific timeline and procedures | Judicial review or federal complaint | Varies by state; some states expedite urgent health decisions |
| Marketplace | Exchange-Level Appeal; varies by exchange and issue type | State Insurance Commissioner complaint or legal action | Limited; focus is on eligibility/subsidy, not medical necessity | Limited expedited options; varies by exchange |
Key Professional Guidance Points
Deadlines Are Critical
Missing a filing deadline typically forecloses the member's right to appeal at that level. Always note the appeal deadline in the denial notice and confirm with the member that they understand when to file. For members facing time pressure, investigate expedited options immediately.
Standard vs. Expedited Tracks
Standard appeals allow the full timeline at each level (e.g., 30 days for an IRE decision). Expedited (or "fast") appeals shorten timelines dramatically when the member's health or ability to function is at immediate risk. Expedited reviews may require clinical documentation. If expedited review is denied by the plan or entity, an automatic escalation to the next level may occur.
Document Preservation
Keep copies of the denial notice, any clinical records supporting the appeal, correspondence with the plan, and all appeal responses. These are essential for escalating to higher levels if needed.
Distinguish Plan Appeals from CMS Appeals
In Medicare Advantage and Part D, the plan conducts the first appeal (and may uphold or reverse). If the plan upholds its decision, the appeal moves to an independent external entity (IRE), which is not part of the plan. Many members confuse these levels; clarify that an IRE review is independent and may result in a different outcome than the plan's decision.
Medicaid Variation
There is no national Medicaid appeals standard. Each state's process, timelines, and remedies differ. Professionals must be familiar with their state's Medicaid appeals procedures and should direct members and colleagues to the state Medicaid agency or plan for specifics.
Related Resources
Your Rights
A comprehensive overview of member rights to appeal, including the right to representation and the right to expedited review.
How Do I…?
Step-by-step guidance on common member actions, including how to file an appeal and what to include.
Health-Plan Operations
Operational overview for professionals on how plans process appeals, make decisions, and interact with external reviewers.
Getting Help Paying
Information on assistance programs and advocates who can help members navigate denials and appeals.
Official Sources for Current Timelines
Appeal timelines and procedures are updated regularly by CMS and state agencies. For the most current information:
- CMS.gov — Original Medicare, Medicare Advantage, Part D appeals information and regulatory updates
- Medicare.gov — Member-facing appeals guidance and deadline tools
- Medicaid.gov — Links to state Medicaid agencies and resources
- HealthCare.gov — Marketplace appeal information
- Your plan's Member Handbook or Summary of Benefits and Coverage (SBC) — specific to each plan's procedures