Medicare Advantage organization determinations and appeals
In a Medicare Advantage plan, a coverage decision is called an organization determination, and the first appeal is a reconsideration by the plan itself. If the plan upholds its denial, Medicare.gov says the case is sent automatically to an Independent Review Entity. That is different from Original Medicare, where the first two levels are a redetermination by the Medicare Administrative Contractor and a reconsideration by a Qualified Independent Contractor. Deadlines are quoted as each source states them; minimum dollar amounts are not copied.
Quoted from official pages checked November 10, 2026. Confirm current requirements, fees, and dates on those sites. This page is not legal advice and does not guarantee eligibility, certification, or licensure.
Sources read on November 10, 2026: Medicare.gov’s Appeals in Medicare health plans page, written for people with Medicare; CMS’s Medicare Managed Care Appeals & Grievances page (page last modified 07/06/2026); and CMS’s Parts C & D Enrollee Grievances, Organization/Coverage Determinations, and Appeals Guidance (PDF, effective July 6, 2026). Original Medicare appeals are on Medicare appeals. Medicare.gov states a minimum dollar amount for levels 3 and 5 each year; those amounts are not copied here.
CMS posts the Parts C & D guidance PDF on cms.gov, and this page links it. The PDF’s own footer states that the information is not releasable to the public unless authorized by law and is for internal government use only. This page quotes only short passages from that publicly posted file. Medicare.gov’s and CMS’s web pages above are the public descriptions.
What an organization determination is
Medicare.gov states: “Coverage decisions in a Medicare Advantage Plan are called ‘Organization Determinations.’” It continues: “An organization determination can be requested by you, your representative, or your health care provider.”
CMS’s guidance states: “An organization determination is any determination (i.e., an approval or denial) made by an MA plan, or its delegated entity with respect to the following:” and lists five kinds of decisions, among them “Reduction, or premature discontinuation, of a previously authorized ongoing course of treatment”. It also says: “In circumstances where there is a question whether or not the plan will cover an item or service, the enrollee, enrollee’s representative, or the provider on behalf of the enrollee, has the right to request approval from the plan.”
CMS separates a coverage decision from a clinician’s own decision: “However, when a provider declines to furnish a service requested by an enrollee, this is not an organization determination because the provider is making a treatment decision”.
CMS defines prior authorization as “The process by which an enrollee or health care provider must obtain approval from a plan before care is provided in order for an item, service, or drug to be covered.” It adds: “Plans must identify items, services, and drugs subject to prior authorization in the enrollee’s Evidence of Coverage.”
Level 1: reconsideration by the plan
Medicare.gov states: “Level 1 appeals in a Medicare Advantage Plan are called ‘Health Plan Reconsiderations.’” On timing: “You, your representative, or your doctor or healthcare provider must file an appeal within 65 days from the date on the initial denial notice sent by your plan.” CMS’s guidance states that a level 1 appeal “Must be filed within 65 calendar days from the date of the notice of the initial determination.”
Who may ask differs by request type in CMS’s guidance. For a standard request for an item or service, the providers who may request an organization determination include a “Contract or non-contract provider/physician that furnishes, or intends to furnish, services to the enrollee.” For a level 1 appeal, CMS lists “The enrollee’s treating physician acting on behalf of the enrollee” and “Any other provider or entity (other than the MA plan) determined to have an appealable interest in the proceeding.” The two lists are left as CMS wrote them.
Medicare.gov lists how long the plan has to respond to a level 1 appeal: “Pre-service appeal: 30 days” and “Payment appeal: 60 days” under the standard process, and “72 hours” for a fast appeal. It says the plan must decide a fast appeal within 72 hours “if it determines, or your doctor tells your plan, that waiting for a standard decision may seriously jeopardize your life, health, or ability to regain maximum function.”
Level 2: the Independent Review Entity
Medicare.gov states: “If the plan decides against you (fully or partially), your appeal is automatically sent to level 2.” And: “If your plan upholds their denial in your level 1 appeal, they’ll automatically forward their reconsideration decision to an Independent Review Entity (IRE) to start a level 2 appeal.” CMS’s guidance says the same for Part C: “All partially favorable or adverse reconsideration decisions are forwarded to the IRE. A party does not have to make a request for a level 2 appeal.”
CMS’s managed care page notes a change of contractor: “Effective May 1, 2026, C2C Innovative Solutions, Inc. (C2C) is the Part C IRE.”
Levels 3 to 5
Medicare.gov states: “You have 60 days from the date of the IRE’s decision to ask for a level 3 appeal, which is a decision by the Office of Medicare Hearings and Appeals (OMHA).” Level 4 is review by the Medicare Appeals Council and level 5 is judicial review in federal district court. Medicare.gov’s level 3 instructions say: “To ask for a hearing before an ALJ, follow the directions on the ‘Medicare Reconsideration Notice’ you got from the Qualified Independent Contractor (QIC) in your level 2 appeal.” Its level 2 section names an Independent Review Entity; both passages are left as Medicare.gov wrote them.
When home health, SNF, or CORF services are ending
CMS’s guidance states: “An enrollee has the right to request an immediate review by the Beneficiary and Family Centered Care Quality Improvement Organization (BFCC-QIO) when a SNF, HHA, or CORF decides to terminate previously approved coverage”. It adds: “All enrollees receiving covered services in these settings must receive a Notice of Medicare NonCoverage (NOMNC), delivered by the facility or provider, before their services end.”
How this differs from Original Medicare
In CMS’s and Medicare.gov’s descriptions, the differences at the start of the process are these: in a Medicare Advantage plan the plan makes the first decision and the first appeal, and a denial goes on to the IRE without a new request; in Original Medicare, the first appeal goes to the Medicare Administrative Contractor and the second is a request to a Qualified Independent Contractor. The details of Original Medicare are on Medicare appeals. The ABN is an Original Medicare notice; see the Medicare ABN. Medicare.gov also notes that PACE plans, Cost plans, and Special Needs Plans have their own appeal descriptions.
What this page does not do
It does not copy minimum dollar amounts, does not say whether any plan must cover a service, and does not describe any particular plan’s prior authorization list. It is not legal, billing, or compliance advice. Confirm current rules with the agency or organization that publishes them, your employer, and your state board.