Medicare Advantage plans: 5 levels of Appeals

mgbrousse
May 19
5 min read

By Martine G. Brousse (not AI!)

"The Medical Bill Whisperer"™

Patient Advocate, Certified Mediator

AdvimedPro

May 19, 2025

Just like Original Medicare, Medicare Advantage plans offer five levels of to their members.

Let's start with some definitions and go over those five levels.

A. Definitions

1. What is Medicare?

It is the federally-run health insurance provided to seniors age 65 and older, or those with a disability, end stage renal disease or Lou Gehrig Disease.

There are two types of Medicare plans: one called "original or straight" directly administered by CMS. It sets policies, supervises the programs, pays claims,

maintains a provider database and keeps updated lists of benefits and medical policies.

Medicare Advantage, also called Part C, is administered by private commercial carriers,

the same ones that offer policies to folks under 65. Those insurance carriers are paid by

Medicare in order to process claims and provide members with access to medical care.

Although there are five levels of appeal for both types of plan, Medicare Advantage plans are the focus on this blog. If your card says Humana, United Healthcare or Blue Cross

Blue Shield, you have a Medicare Advantage plan. Original Medicare plans members should refer to this separate blog.

2. What is an Appeal ?

It is your right to request that the insurance reviews its denial, rejection of coverage, adverse decision or that it reviews how a claim was processed.

It is your member's and Medicare right to request a reconsideration of a decision based on your medical records, facts, circumstances, legal mandates, Medicare benefits, etc.

It is your right as a Medicare patient to request, if not demand, that payment be made on your behalf when it was initially denied or rejected.

B. 5 levels of appeals

1. Level 1: "Redetermination"

That appeal goes back to the insurance company that processed your claim or rejected an authorization request.

The appeals department contact information will be indicated on the Explanation Of Benefit or document that you have received from that carrier. It should be posted online or can be obtained by calling customer service. A special form is needed and available through your online portal or by calling a rep.

Most decisions are issued within 30 days if you have requested an authorization for service or treatment, or 60 days if that has already been performed and you seek payment.

Cases when your health, life or ability to regain your maximum functions require a faster review and decision than 30 days, do file for an "Expedited Reconsideration". It usually takes up to 72 hours.

Should you be fighting a discharge from an inpatient hospital or discontinued services at your current skilled nursing facility, rehab facility or through a home health agency, you should request what is called an "Immediate Review", and as the name indicates, a decision will be prompt.

2. Level 2: “IRE” (“Independent Review Entity”)

If denied, the decision letter will indicate that the Medicare Advantage plan you belong to as automatically forwarded your appeal to an IRE or “Independent Review Entity”.

These independent external reviewers have not taken part in the level 1 determination.

Their decision is usually within 30 days (for an authorization) - 60 days (if requesting payment for services already rendered) or 7 days (Part B drugs).

Should that decision also be negative, you must handle the next levels of appeals yourself.

3. Level 3: “OMH” (Office of Medicare Hearings and Appeals)

A special form will be required to request that an Administrative Law Judge (“ALJ”) review your case and issue a decision.

Hearings are usually via zoom or phone but can be held in person, if the Judge decides so. You also have the right not to have a hearing at all (special form required).

If you prefer, the option to have a representative appear at that hearing on your behalf only requires a special form. Yes, another form.

4. Level 4: Medicare Appeals Council Review

If the ALJ has ruled against you, all is not lost. But this 4th level appeal can only be filed via snail mail (with a special form).

Submit your documentation, justification, evidence and another judge will review your case and rule on the previous judge’s decision.

5. Level 5: Judicial Review in Federal District Court

The level 4 negative decision letter would indicate how and where to file for this final appeal.

C. The case of SNPs (“Special Needs Plans”)

There is a special type of Medicare Advantage plan called Special Needs Plans.

This includes Medicare members who have Part C Medicare Advantage with Medicaid, or who live in a nursing home or who suffer from certain chronic medical conditions. Those special plans provide focused and specialized health care for those members.

The appeal process is a little bit different, at least at the beginning.

1. level 1: Each plan or insurance company is different. Each should be able to tell you in writing how to appeal. The appeal will go to the same plan or insurance company that has made the original decision.

2. Level 2: automatic IRE

If you lose that first level appeal, it is then automatically sent by your plan to an independent, external organization that is not connected to your insurance, but works for Medicare. For members who also have Medicaid, an appeal may also be sent to your State Fair Hearing. Usually the process is streamlined to cover both Medicare and Medicaid levels in one swoop.

3. Levels 3,4 5:

If that is unsuccessful, appeal levels 3,4 and 5 are split again. They either follow the regular appeal levels 3-4-5 for Medicare as described above or go through the state's Medicaid appeals level process. Each of the 50 states has its own regulations and protocols, which are impossible to fit into the scope of this video. Contacting your own state's Medicaid office is the best recommendation.

D. Important Points

1. Timeliness is strict and strictly enforced

From the date of your Explanation Of Benefit, denial letter or Medicare Remittance Advice notice, you have only 60 days (some say 65) to file that first level appeal with your own insurance carrier.

The second level appeal will be automatically sent, so nothing to worry about.

But after that, do keep in mind a 60-day limit between level 2 and up.

2. There are exceptions to timeliness … maybe

The deadline may be extended if you can prove:

· you were ill, incapacitated or in a hospital or facility.

· A close family member had a serious illness or death that you had to deal with

· Medical records or other documentation were lost, damaged or took time to obtain

· Information given by an insurance or Medicare representative was incorrect or confusing

· You needed time to hire an advocate, an attorney, or to find an appropriate representative.

3. Minimum$ amounts

To file for hearing with a Judge at level three, you must show $190 in contested claims, and to file at level five, that would be $1,850.

4. Seek help

· SHIP, the State Health Insurance Assistance Program has folks and resources ready to give you free advice and assistance with that appeal process. Google: SHIP Medicare + your state to get connected to your local office.

· Consider hiring a specialized advocate. Once you have signed and filed the Appointment Of Representative form, that advocate can act on your behalf, whether to file a written appeal or appear at your level 3 hearing.

· Speaking of legal process proceedings, an attorney specializing in Medicare law could be helpful, especially at level 5.

In Conclusion:

I've always found that the key to success is not so much blind luck, but good preparation, supportive evidence and a clear, precise, concise presentation.

Whether in writing or at a hearing, winning a Medicare Advantage appeal should not be a game of chance. After all, it is your money we are talking about.

Martine Brousse was a long-time Billing Manager for Physicians before switching to the side of patients in 2013. The move has allowed her to apply her deep expertise and vast experience of the intricacies of resolving all types of medical bill and claim payment issues in ways that directly and positively impact her clientsʻ finances.