Medicare Advantage: your appeal rights

Your Medicare Advantage plan must give you a written decision when it denies a service or payment. A standard service decision is due within 14 calendar days (7 calendar days for items subject to prior authorization, beginning January 1, 2026); an expedited decision within 72 hours (24 hours for a Part B drug); a payment decision within 60 calendar days. If the plan misses its deadline, that failure itself counts as a denial you can appeal — it is not an automatic approval.

The filing rule is 60 calendar days after receipt of the denial notice. Receipt is presumed 5 calendar days after the notice date unless there is evidence otherwise. CMS describes this as a 65-calendar-day notice-date default; if actual receipt is known, the receipt-based rule controls. The request is filed when the plan or its designated delegated entity receives it, not when it is sent or postmarked. Ensure the request is received by that recipient by the filing deadline and retain proof of receipt. A different reviewer than the one who denied you must decide. If the denial was for medical reasons, a physician with expertise appropriate to the service must review it; the physician need not always share the treating physician's specialty or subspecialty. If the plan misses a reconsideration deadline, it must forward the case to the Independent Review Entity rather than make you start a new appeal. An expedited reconsideration missed deadline requires forwarding within 24 hours; a missed deadline does not automatically approve the service.

If your plan upholds its denial in whole or in part, it must forward your case to an Independent Review Entity without a separate patient filing. For a standard service reconsideration, the plan must send the case file by the applicable 30-calendar-day deadline, subject to a permitted extension; expedited adverse reconsiderations must be forwarded within 24 hours. The IRE's decision clock starts when it receives the case file, not when the plan sends it. The IRE may extend a non-Part-B-drug review by up to 14 calendar days if the enrollee requests it or case-file deficiencies require action, with appropriate notice and documented justification. This is separate from a plan reconsideration extension. Confirm receipt and the applicable deadline with the IRE.

For services or items not yet furnished, you may request expedited reconsideration orally or in writing. The plan must expedite when it determines that the standard timeframe could seriously jeopardize your life or health or ability to regain maximum function. It must also expedite when a physician makes or supports the request and indicates that same jeopardy standard is met; physician support alone, without that indication, is not the rule. The expedited reconsideration decision is due within 72 hours for both services and Part B drugs. A permitted extension of up to 14 calendar days may apply to services or items, but not Part B drugs. Requests for payment of services already furnished do not qualify for expedited reconsideration.

If the IRE also says no and the amount in dispute meets the yearly threshold, you can request a hearing before an Administrative Law Judge within 60 calendar days after receiving the IRE notice. Receipt is presumed 5 calendar days after the notice date unless there is evidence otherwise. Levels 4 and 5 (Medicare Appeals Council, federal court) exist beyond that.

If your Medicare drug plan (including MA-PD plans) says a drug isn't on the formulary, wants you to try another drug first, limits the dose, or puts it on an expensive tier, you can demand an exception. Your prescriber submits a supporting statement — that the formulary alternatives would not be as effective for you, would cause adverse effects, or both — and the plan must decide within 72 hours (24 hours expedited) of receiving that statement. An exception request IS a coverage determination; if the plan misses its deadline, your case must be automatically forwarded to the independent review entity within 24 hours.

An MA plan may apply step therapy to physician-administered (Part B) drugs only for NEW starts — if you've received the drug within the past 365 days, step therapy can't be applied to you. Step-therapy programs must be approved by the plan's pharmacy and therapeutics committee. Relief runs through the normal organization-determination track, where a decision on a Part B drug is due in 24 hours when expedited.

Under the 2026 CMS prior-authorization rule (CMS-0057-F), beginning January 1, 2026, impacted payers — Medicare Advantage plans, Medicaid and CHIP (fee-for-service and managed care), and Qualified Health Plans on the federal Marketplace — must include a specific reason when they deny a prior-authorization request for an item or service (drugs are excluded). You can also ask the plan for the criteria, guideline or policy it applied; that is a request, not something this rule requires. (This rule does not reach most commercial or self-funded employer/ERISA plans.)

Insurers must cover emergency care based on your symptoms at the time — not the final diagnosis. If a reasonable person would have thought it was an emergency, it must be covered as one, in or out of network, with no prior authorization required.

For emergency care and for out-of-network providers working at in-network facilities, you can only be billed your in-network cost sharing. Balance bills in those situations are illegal — dispute them rather than paying. (Ground ambulance bills are not covered by these protections.)